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Incidental neuroendocrine tumor of a complete subserosal appendix: an unusual presentation of a rare anatomical variation. A case report and review of literature. BMC Surg 2021; 21:421. [PMID: 34915872 PMCID: PMC8680036 DOI: 10.1186/s12893-021-01429-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/12/2021] [Indexed: 01/21/2023] Open
Abstract
Background Appendix’ anatomical variations are a rare occurrence which can mislead diagnosis and delay appropriate treatment.
Case presentation We present a 9-year-old female patient that came with a clinical picture compatible with acute appendicitis. However, a cecal mass was identified instead of an inflamed appendix during surgery. Therapeutic decisions were extremely challenging due to clinical deterioration and an uncertain etiology. Only the histopathology report revealed the presence of a complete subserosal appendix which was responsible for the entire symptomatology. Here, we review all case reports regarding intramural, intracecal or subserosal appendixes. A discussion of the general approach to this specific case and the importance of consensual diagnostic criteria for these specimens are also presented. At last, an incidental finding is exposed and final treatment options are discussed given the overall presentation. Conclusions Considering these variants would guide physicians towards a more accurate approach to similar clinical pictures and hence an improved long-term prognosis.
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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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Balasubramaniam D, Duraisamy KY, Chinnusamy P, Nethaji S, Karunanithi S. Feasibility of Laparoscopic Hysterectomy in Stage IV Pelvic Endometriosis: Our Technique and Outcomes. J Midlife Health 2020; 11:27-33. [PMID: 32684724 PMCID: PMC7362979 DOI: 10.4103/jmh.jmh_69_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 02/28/2020] [Indexed: 11/24/2022] Open
Abstract
Context: The definitive surgical treatment of severe endometriosis remains to be hysterectomy whether done by laparoscopy or laparotomy. Aim: The aim of this study was to assess the feasibility and outcome of laparoscopic hysterectomy in severe pelvic endometriosis. Settings and Design: This retrospective study was carried out in a tertiary center over a period of 5 years (January 2013–December 2017). Subjects and Methods: A total of 70 patients who underwent laparoscopic hysterectomy for severe pelvic endometriosis with a score of more than 40, which was defined by the revised American Fertility Society classification, were included in the study. Feasibility of laparoscopic hysterectomy and other clinical parameters such as operative time, blood loss, recurrence of the disease, and need for postoperative medical treatment was analyzed. Results: The mean age of the patients was 43.2 ± 4.56. Majority of the women (62.8%) had dysmenorrhea as the primary complaint, followed by menorrhagia (21.4%). Intraoperatively rectovaginal septum was involved in 95% of the cases with complete obliteration of the pouch of Douglas in 80% of the cases. The ureter was involved in 34% of the cases. The bladder was densely adherent in 71.4% of the patients. There was no conversion to laparotomy in any of these patients and no visceral injuries. The mean duration of surgery was 3 h. The estimated blood loss ranged from 100 to 500 ml. The duration of hospital stay was 2–5 days. There was no recurrence during follow-up in any of these patients. Conclusions: Laparoscopy in experienced hands is feasible and safe even in difficult cases of Stage IV pelvic endometriosis apart from offering superior results.
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Affiliation(s)
| | | | | | - Swathi Nethaji
- Department of Endogynaecology, GEM Hospital, Coimbatore, Tamil Nadu, India
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Cai CW, Sisler KE, Gavard JA, Eugenio-Colon JD, Yeung PP. Abnormal pathology seen on appendectomy in patients with predominant right-sided pelvic pain. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2020. [DOI: 10.1177/2284026520924904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Previous studies have linked chronic pelvic pain (CPP) to appendix pathologies. However, few studies have investigated appendix pathology specifically in the context of CPP that is right-side predominant (R-CPP). We hypothesized that women with R-CPP have higher rates of appendix pathology compared with women with CPP that is not right-side predominant (N-CPP). Methods: We conducted a retrospective case–control study of 220 women who underwent diagnostic laparoscopy and planned or incidental appendectomy for CPP and suspected endometriosis between January 2015 and December 2018 at a tertiary care center in Saint Louis, MO. Results: No significant difference in abnormal appendix pathology was found between women with R-CPP and women with N-CPP (30.9% vs 34.5%, p = 0.74, odds ratio = 0.85, 95% CI: (0.44, 1.62)). Gross abnormalities of the appendix were documented in 40 of 220 patients (18.2%), with the most common abnormal gross findings being adhesions (8.2%), followed by abnormal lesions (7.3%). Conclusion: In this study, the presence of abnormal pathology within the appendix did not correlate with R-CPP, indicating triage based on predominant pain location cannot help identify patients with underlying appendix pathology. However, consistent with previous studies, we identified a high rate of abnormal appendix pathology overall, supporting the practice of many surgeons to perform routine appendectomy in women with CPP.
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Affiliation(s)
- Catherine W Cai
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Katelin E Sisler
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Jeffrey A Gavard
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Jose D Eugenio-Colon
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, USA
| | - Patrick P Yeung
- Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St. Louis, MO, 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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Wong SL, To V, Lam J, Lam A. Metastatic neuroendocrine tumour mimicking endometriosis highlights the importance of excision for tissue diagnosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2019. [DOI: 10.1177/2284026519838717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Endometriosis is a common gynaecological condition, usually presenting with pelvic pain or infertility in women of reproductive age. Diagnosis is made on histopathology of deposits excised during laparoscopy, given diagnosis solely made by macroscopic examination can be challenging for even experienced gynaecological surgeons. Case description: A 45-year-old during laparoscopy for fibroids is found to have peritoneal deposits resembling endometriosis. Histopathology reveals multifocal metastatic grade 1 neuroendocrine tumour of the appendix. Conclusion: This incidental finding highlights the importance of thorough examination of the appendix and abdominal cavity for unexpected pathology during gynaecological laparoscopy. Incidental finding of appendiceal pathology at time of laparoscopy for endometriosis is not uncommon; however, the finding of metastatic malignancy is far rarer. While several case studies have reported severe endometriosis mimicking advanced stage cancer, this is the first documented occurrence of an advanced, metastatic tumour, mimicking endometriosis.
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Affiliation(s)
- Shian-Li Wong
- Centre for Advanced Reproductive Endosurgery, St Leonards, NSW, Australia
| | - Valerie To
- Centre for Advanced Reproductive Endosurgery, St Leonards, NSW, Australia
| | - Justin Lam
- Centre for Advanced Reproductive Endosurgery, St Leonards, NSW, Australia
| | - Alan Lam
- Centre for Advanced Reproductive Endosurgery, St Leonards, NSW, Australia
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Mabrouk M, Raimondo D, Mastronardi M, Raimondo I, Del Forno S, Arena A, Sutherland N, Borgia A, Mattioli G, Terzano P, Seracchioli R. Endometriosis of the Appendix: When to Predict and How to Manage-A Multivariate Analysis of 1935 Endometriosis Cases. J Minim Invasive Gynecol 2019; 27:100-106. [PMID: 30849476 DOI: 10.1016/j.jmig.2019.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVE To evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery. DESIGN A retrospective cohort study. SETTING A tertiary level referral center, university hospital. PATIENTS One thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis. INTERVENTIONS Electronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants. MEASUREMENTS AND MAIN RESULTS AE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32-4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08-15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63-29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05-3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82-11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10-4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07-75.75). CONCLUSION Among patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.
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Affiliation(s)
- Mohamed Mabrouk
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli); Department of Obstetrics and Gynecology, Faculty of Medicine, University of Alexandria, Alexandra, Egypt (Dr. Mabrouk)
| | - Diego Raimondo
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli).
| | - Manuela Mastronardi
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Ivano Raimondo
- Department of Obstetrics and Gynecology, University of Sassari, Sassari, Italy (Dr. Raimondo)
| | - Simona Del Forno
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Alessandro Arena
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Neveta Sutherland
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli); Department of Obstetrics and Gynecology, Victoria Jubilee Hospital, University of the West Indies, Mona, Jamaica (Dr. Sutherland)
| | - Alessandra Borgia
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Giulia Mattioli
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Patrizia Terzano
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
| | - Renato Seracchioli
- Department of Obstetrics and Gynecology, Dipartimento di Scienze Mediche e Chirurgiche, S Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Mabrouk, Raimondo, Mastronardi, Del Forno, Arena, Sutherland, Borgia, Mattioli, Terzano, and Seracchioli)
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The role of appendectomy at the time of laparoscopic surgery for benign gynecologic conditions. Curr Opin Obstet Gynecol 2019; 30:237-242. [PMID: 29889113 DOI: 10.1097/gco.0000000000000466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The risk-benefit ratio of concurrent appendectomy at the time of gynecologic surgery has long been debated and remains controversial. However, emerging data on the appendix's role in chronic pain syndromes point to a previously unrecognized link between gynecologic disorders and appendicular pathology. In this article, we review the indications for appendectomy at the time of laparoscopic gynecologic surgery for the treatment of endometriosis and chronic pelvic pain. RECENT FINDINGS The incidence of appendiceal endometriosis is highly variable depending on the patient population selected. Although rare in patients undergoing appendectomy for acute appendicitis, women with endometriosis may experience rates as high as 9.3-39.0%, especially when suffering from deep infiltrative endometriosis. Appendectomy may also significantly reduce pain in women with unexplained chronic pelvic pain. SUMMARY Despite lack of prospective data, retrospective studies suggest that appendectomy during gynecologic procedures for chronic pelvic pain and severe endometriosis may be beneficial and necessary to fully address the treatment of these complex gynecologic conditions. In these clinical scenarios, the benefits of laparoscopic appendectomy at the time of the primary gynecologic procedure may outweigh the risks and cost, and should be discussed with patients preoperatively.
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Leyland N, Casper R, Laberge P, Singh SS, Allen L, Arendas K, Leyland N, Allaire C, Awadalla A, Best C, Contestabile E, Dunn S, Heywood M, Leroux N, Potestio F, Rittenberg DA, Singh SS, Soucy R, Wolfman WL, Senikas V. Endometriosis: Diagnosis and Management. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/228402651000200303] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis. Outcomes Outcomes evaluated include the impact of the medical and surgical management of endometriosis on women's experience of morbidity and infertility. Methods Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. Results This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. Conclusions Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy. Evidence Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis. Values The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1. Benefits, harms, and costs Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.
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Altman AD, Lefas G, Power L, Lambert P, Lotocki R, Dean E, Nachtigal MW. Rate of Appendiceal Metastasis with Non-Serous Epithelial Ovarian Cancer in Manitoba. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 40:180-185. [PMID: 28826644 DOI: 10.1016/j.jogc.2017.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/24/2017] [Accepted: 05/31/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study sought to evaluate the rate of appendiceal involvement in non-serous mucinous and endometrioid-associated epithelial ovarian cancers. METHODS The Manitoba Cancer Registry and CancerCare database were used to find all women with non-serous epithelial ovarian, fallopian tube, or primary peritoneal cancer between 1995 and 2011. All patients with an appendectomy were then identified, and their final pathology findings were reviewed. Women who did not receive treatment or lacked follow-up were excluded. RESULTS We identified 338 patients from 1995-2011 with no prior appendectomy. Of these, 16.6% received an appendectomy, and 22.8% were clinically evaluated. Most cases within this cohort were mucinous (62%) and stage 1 (63%). Four appendiceal metastases were identified (7.2%), and one half appeared clinically normal at the time of surgery (3.6%). Within the mucinous histologic type, 32.7% of patients received an appendectomy, with a metastatic rate of 5.7%. Of the 127 endometrioid cases, only 10 patients received an appendectomy, and 2 were found to have metastases. No metastases were found in the 85 patients in the clear cell cohort, only 5 of whom received an appendectomy. CONCLUSION Routine appendectomy or clinical assessment of the appendix is valuable for all non-serous ovarian cancers. The rate of involvement for endometriosis-associated ovarian cancers may be significantly higher than expected, and further studies need to be conducted.
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Affiliation(s)
- Alon D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB; Division of Gynecologic Oncology, CancerCare Manitoba, Winnipeg, MB.
| | - Georgia Lefas
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Laura Power
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Pascal Lambert
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB
| | - Robert Lotocki
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB; Division of Gynecologic Oncology, CancerCare Manitoba, Winnipeg, MB
| | - Erin Dean
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB; Division of Gynecologic Oncology, CancerCare Manitoba, Winnipeg, MB
| | - Mark W Nachtigal
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB; Department of Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, MB; Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB
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12
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Moulder JK, Siedhoff MT, Melvin KL, Jarvis EG, Hobbs KA, Garrett J. Risk of appendiceal endometriosis among women with deep-infiltrating endometriosis. Int J Gynaecol Obstet 2017; 139:149-154. [DOI: 10.1002/ijgo.12286] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/02/2017] [Accepted: 07/26/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Janelle K. Moulder
- Division of Minimally Invasive Gynecologic Surgery; Department of Obstetrics and Gynecology; University of North Carolina; Chapel Hill NC USA
- University of Tennessee Medical Center; Knoxville TN USA
| | - Matthew T. Siedhoff
- Division of Minimally Invasive Gynecologic Surgery; Department of Obstetrics and Gynecology; Cedars-Sinai Medical Center; Los Angeles CA USA
| | | | - Elizabeth G. Jarvis
- Department of Obstetrics and Gynecology; WakeMed Physician Practices; Raleigh NC USA
| | - Kumari A. Hobbs
- Department of Obstetrics and Gynecology; New York-Presbyterian/Lower Manhattan Hospital; New York NY USA
| | - Joanne Garrett
- Division of Family Planning; Department of Obstetrics and Gynecology; University of North Carolina; Chapel Hill NC USA
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13
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Newhall K, Albright B, Tosteson A, Ozanne E, Trus T, Goodney PP. Cost-effectiveness of prophylactic appendectomy: a Markov model. Surg Endosc 2017; 31:3596-3604. [PMID: 28078461 DOI: 10.1007/s00464-016-5391-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 12/15/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Appendectomy is the most common emergency surgery performed in the USA. Removal of a non-inflamed appendix during unrelated abdominal surgery (prophylactic or incidental appendectomy) can prevent the downstream risks and costs of appendicitis. It is unknown whether such a strategy could be cost saving for the health system. METHODS We considered hypothetical patient cohorts of varying ages from 18 to 80, undergoing elective laparoscopic abdominal and pelvic procedures. A Markov decision model using cost per life-year as the main outcome measure was constructed to simulate the trade-off between cost and risk of prophylactic appendectomy and the ongoing risk of developing appendicitis, with downstream costs and risks. Rates, probabilities, and costs of disease, treatment, and outcomes by patient age and gender were extracted from the literature. Sensitivity analyses were conducted using complications and costs of prophylactic appendectomy. RESULTS With our base-case assumptions, including added cost of prophylactic appendectomy of $660, we find that prophylactic removal of the appendix is cost saving for males aged 18-27 and females aged 18-28 undergoing elective surgery. The margin of cost savings depends on remaining life-years and increases exponentially with age: a 20-year-old female undergoing elective surgery could save $130 over a lifetime by undergoing prophylactic appendectomy, while a 40-year-old female would lose $130 over a lifetime. When the risk of the prophylactic appendectomy exceeds the risk of laparoscopic appendectomy for appendicitis or the cost exceeds $1080, it becomes more cost saving to forego the prophylactic procedure. CONCLUSIONS Prophylactic appendectomy can be cost saving for patients younger than age thirty undergoing elective laparoscopic abdominal and pelvic procedures.
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Affiliation(s)
- Karina Newhall
- VA Outcomes Group, White River Junction Veterans Affairs Hospital, White River Junction, VT, USA. .,Department of Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA.
| | | | - Anna Tosteson
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elissa Ozanne
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Thadeus Trus
- Department of Surgery, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, USA
| | - Philip P Goodney
- VA Outcomes Group, White River Junction Veterans Affairs Hospital, White River Junction, VT, USA.,Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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14
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Gomes CA, Sartelli M, Di Saverio S, Ansaloni L, Catena F, Coccolini F, Inaba K, Demetriades D, Gomes FC, Gomes CC. Acute appendicitis: proposal of a new comprehensive grading system based on clinical, imaging and laparoscopic findings. World J Emerg Surg 2015; 10:60. [PMID: 26640515 PMCID: PMC4669630 DOI: 10.1186/s13017-015-0053-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/24/2015] [Indexed: 12/29/2022] Open
Abstract
Advances in the technology and improved access to imaging modalities such as Computed Tomography and laparoscopy have changed the contemporary diagnostic and management of acute appendicitis. Complicated appendicitis (phlegmon, abscess and/ or diffuse peritonitis), is now reliably distinguished from uncomplicated cases. Therefore, a new comprehensive grading system for acute appendicitis is necessary. The goal is review and update the laparoscopic grading system of acute appendicitis and to provide a new standardized classification system to allow more uniform patient stratification. During the last World Society of Emergency Surgery Congress in Israel (July, 2015), a panel involving Acute Appendicitis Experts and the author’s discussed many current aspects about the acute appendicitis between then, it will be submitted a new comprehensive disease grading system. It was idealized based on three aspect of the disease (clinical and imaging presentation and laparoscopic findings). The new grading system may provide a standardized system to allow more uniform patient stratification for appendicitis research. In addition, may aid in determining optimal management according to grade. Lastly, what we want is to draw a multicenter observational study within the World Society of Emergency Surgery (WSES) based on this design.
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Affiliation(s)
- Carlos Augusto Gomes
- Surgery Department, Therezinha de Jesus University Hospital, Medical and Health Science School, Surgery Unit, Federal University of Juiz de Fora (UFJF), Rua Senador Salgado Filho 510 / 1002, Bairro Bom Pastor, Juiz de Fora, Minas Gerais 36021-660 Brasil
| | | | | | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | | | - Kenji Inaba
- University of California, San Francisco, USA
| | - Demetrios Demetriades
- University of California, San Francisco, USA ; Department of Surgery (K.I.), Keck School of Medicine of University of Southern California, Los Angeles, CA USA
| | - Felipe Couto Gomes
- Internal Medicine Departament, Therezinha de Jesus University Hospital, Medical and Health Science School, Juiz de Fora, Brazil
| | - Camila Couto Gomes
- Internal Medicine Departament, Monte Sinai Hospital, Juiz de Fora, Minas Gerais Brazil
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15
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Benton AS, Riley KA, Harkins GJ. The Use of a Robotic Stapling Device for Coincidental Appendectomy. J Gynecol Surg 2015. [DOI: 10.1089/gyn.2014.0101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrea S. Benton
- Department of Obstetrics and Gynecology, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA
| | - Kristin A. Riley
- Department of Obstetrics and Gynecology, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA
| | - Gerald J. Harkins
- Department of Obstetrics and Gynecology, Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, PA
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16
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Jocko JA, Shenassa H, Singh SS. The role of appendectomy in gynaecologic surgery: a canadian retrospective case series. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 35:44-8. [PMID: 23343796 DOI: 10.1016/s1701-2163(15)31047-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To review the indications for, and the associated pathology and complications of, appendectomy performed during gynaecologic surgery in a tertiary academic health sciences centre. METHODS We performed a retrospective review of appendectomy cases performed from September 2007 to December 2011 in a tertiary level gynaecologic surgical practice. Cases were reviewed using a standardized intake sheet with surgical reports, history, and pathologic findings. RESULTS A total of 71 appendectomies were performed during gynaecologic surgery in the study period. All cases were primary gynaecologic surgical cases; the most common diagnoses were endometriosis, pelvic pain, and pelvic mass. Overall, 42 (59%) of the study cases had abnormal histopathology in the appendix. Of the 44 women with a primary diagnosis of endometriosis, 28 (64%) had positive appendiceal pathology. In women with chronic pelvic pain, three of eight (38%) had pathology within their appendix. Of all appendixes removed that appeared normal on gross inspection, irrespective of diagnosis, 44% had positive pathology. CONCLUSION When a structured approach is taken towards assessment of the appendix during gynaecologic surgical cases, with removal when indicated, a high rate of pathology may be found. In this series, there were no complications directly related to the appendectomy, providing support for the contention that appropriately trained gynaecologists can safely perform appendectomy. The findings in this Canadian series are in keeping with previous reports and support the need for evaluation and removal of the appendix when indicated at the time of gynaecological surgery.
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Affiliation(s)
- Jennifer A Jocko
- Department of Obstetrics and Gynecology, The Ottawa Hospital, The University of Ottawa, The Ottawa Hospital Research Institute, Ottawa ON
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17
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Lal AK, Weaver AL, Hopkins MR, Famuyide AO. Laparoscopic appendectomy in women without identifiable pathology undergoing laparoscopy for chronic pelvic pain. JSLS 2013; 17:82-7. [PMID: 23743376 PMCID: PMC3662750 DOI: 10.4293/108680812x13517013317031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Laparoscopic appendectomy is suggested to be effective therapy for women with chronic pelvic pain of unknown etiology. Objectives: To assess the effectiveness of appendectomy in women undergoing laparoscopy for chronic pelvic pain without identifiable pathology. Methods: This retrospective cohort study included women aged 15 to 50 years who underwent laparoscopic surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women who underwent appendectomy and women who had not undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by subsequent mailed questionnaire. Results: Women who underwent appendectomy (n = 19) were significantly more likely to report improvement in pain at 6-week follow-up than women who did not undergo appendectomy (n = 76) (93% vs 16%; P < .001). Thirty-six patients (38%) responded to the questionnaire at a median of 4.2 years after surgery, when the median change (improvement) in reported pain was greater in the appendectomy group than in the nonappendectomy group. Conclusion: Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who are undergoing laparoscopy.
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Affiliation(s)
- Ann K Lal
- Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL, USA
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18
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Endometriosis of the Appendix: The Experience of General Surgeons in a Large Teaching Hospital. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2013. [DOI: 10.5301/je.2013.11017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Endometriosis presents frequently to the general surgeon both electively and as an emergency. One reason for this is that the symptoms from endometriosis may mimic appendicitis. Endometriosis is not closely associated with appendicitis but numerous case reports of appendiceal endometriosis exist in the literature. We reviewed all cases of appendiceal endometriosis from a large UK teaching hospital over a ten-year period to determine how this rare entity may present. Seven cases were identified and the case notes retrieved. Based on histology findings, two patients were found to have appendiceal endometriosis in association with acute appendicitis. In three cases, endometrial deposits were found in their appendix with evidence of previous endometriosis-associated inflammation. The finding of appendiceal endometriosis was incidental in a further two cases. Evidence for an association between endometriosis and appendicitis and the evidence for appendicectomy at the time of laparoscopic-diagnosis of endometriosis is discussed.
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19
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Malhotra V, Nanda S, Chauhan MB, Ahuja K, Mishra T, Mathur S. Endometriosis of the Appendix: Incidental Diagnosis. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vani Malhotra
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Smiti Nanda
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Meenakshi B. Chauhan
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Kamlesh Ahuja
- Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Tushar Mishra
- Department of Surgery, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - S.K. Mathur
- Department of Pathology, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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20
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Al-Talib A, Tulandi T. The Place Of Appendectomy in Women with Chronic Pelvic Pain and Pelvic Endometriosis. J Gynecol Surg 2011. [DOI: 10.1089/gyn.2010.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ayman Al-Talib
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
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21
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Lee JH, Choi JS, Jeon SW, Son CE, Bae JW, Hong JH, Lee KW, Lee YS. Laparoscopic incidental appendectomy during laparoscopic surgery for ovarian endometrioma. Am J Obstet Gynecol 2011; 204:28.e1-5. [PMID: 20887970 DOI: 10.1016/j.ajog.2010.08.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 07/01/2010] [Accepted: 08/24/2010] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We sought to investigate the safety and efficacy of laparoscopic incidental appendectomy during laparoscopic surgery for endometrioma. STUDY DESIGN We conducted a retrospective study of 356 patients undergoing laparoscopic surgery for endometrioma with appendectomy (appendectomy group, n = 172) or not (nonappendectomy group, n = 184). Primary outcome measures were operating time, hemoglobin change, hospital stay, return of bowel activity, and any complications. The secondary outcome was appendiceal histopathology. RESULTS There were no statistical differences between groups in operating time, postoperative changes in hemoglobin concentration, hospital stay, return of bowel activity, or complication rate. Of the 172 resected appendices, 52 had histopathologically confirmed abnormal findings including appendiceal endometriosis in 16. CONCLUSION Incidental appendectomy at the time of laparoscopic surgery for endometrioma does not increase operative morbidity, and it has considerable diagnostic and preventive value. However, a large prospective randomized study is needed in the future to confirm this conclusion.
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23
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Lim MC, Song YJ, Lee DO, Jung DC, Yoo CW, Park SY. Appendectomy in retrograde order for complete removal of endometriosis. Gynecol Endocrinol 2009; 25:844-7. [PMID: 19906005 DOI: 10.3109/09513590903056142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Endometriosis frequently involves the intestines. Appendectomy would be often required as part of complete removal of endometriosis. We present a patient with endometriosis who required very difficult appendectomy. For complete removal of endometriosis, hysterectomy, bilateral salpingooophorectomy, low anterior resection and accompanying pelvic peritonectomy were performed through a mid-line incision. Unexpectedly, the appendiceal tip was attached to peri-hepatic tissue with the appendix adhered to the surrounding peritoneum and bowel. Completion of the appendectomy was possible in retrograde order after extension of the surgical incision above the umbilicus. Our findings suggest that preoperative image evaluation for location or position of the appendix might be helpful in patients with suspected endometriosis to offer correct counselling, obtaining adequate consent, determining the optimal surgical approach and scheduling opportune intraoperative consultation by a colorectal surgeon.
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Affiliation(s)
- Myong Cheol Lim
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Ilsandong-gu, Goyang-si, Gyeonggi-do, Korea
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