The Place Of Appendectomy in Women with Chronic Pelvic Pain and Pelvic Endometriosis

Introduction

Endometriosis is commonly encountered in women of reproductive age. This condition is usually found in the posterior cul de sac and ovary and is seen more frequently in the left hemipelvis.^1,2 The diagnosis is established by laparoscopy or laparotomy and by histopathologic examination. ³ The most common location of extragenital endometriosis is the intestines, and 3% of intestinal endometriosis is located in the appendix. ⁴ Of 71,000 appendectomies, endometriosis of the appendix was found in 0.05% of cases. ⁵ The incidence of appendiceal endometriosis could be as high as 20%.^6–7 This wide range could be the result of variation in the appearance of appendiceal endometriosis. In fact, 38% of grossly normal-appearing appendices have histological evidence of endometriosis. ⁷

Researchers reported, in a prior review, that, in the presence of pelvic endometriosis, the prevalence odds ratio of appendiceal endometriosis compared to the general population was 20.9 (95% confidence interval 16.6–26.4). ⁸

Clinical Presentation

Intestinal endometriosis is usually asymptomatic and found incidentally during surgery for other conditions. Symptoms may vary between pelvic pain and irritable bowel symptoms and are often dependent on the location of the endometriosis. ⁹ In addition to cyclic and chronic right lower quadrant pain, the patient can present with symptoms of acute and chronic appendicitis.^10–15 Other symptoms range from constipation ¹⁶ to low intestinal bleeding and bowel intussusceptions.^17–19

Pathophysiology

Endometriosis of the appendix usually involves the serosa or both serosa and muscularis propria. ²⁰ Acute appendicitis as a manifestation of endometriosis is rare. ¹⁰ In a study of 16 cases of appendiceal endometriosis, 6 of them presented as acute appendicitis. Catamenial appendicitis has also been described. ²¹ Endometriosis implants were found in the body of the appendix in 56% of the cases and on the tip of the appendix in the remaining 44%. In all cases, endometrial glands and stroma were encountered.

Similar to normal endometrium, endometriosis tissue (stroma and glands) in the appendix undergo cyclic functional changes that might cause cyclic abdominal pain. A continuous inflammatory process in the appendix can lead to appendiceal fibrosis (Fig. 1). This fibrosis might cause intermittent obstruction of the appendix leading to fulminant acute appendicitis, ²² or chronic pelvic pain arising from chronic appendicitis. Invaginations of the appendix and intestinal intussusception have also been described. ²³

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FIG. 1.

Gross appearance of endometriosis-harbored appendix.

Diagnosis

Preoperative diagnosis of appendiceal endometriosis is difficult. To date, there has been no preoperative symptom or examination that is specific for predicting appendiceal involvement of endometriosis. ²⁴ In addition, there is no specific radiologic test for diagnosing this condition. Laparoscopy provides detailed evaluation of the appendix, and yet the intraoperative diagnosis is not always correct.

Role of Appendectomy

Involvement of the appendix may contribute to pelvic pain in women with endometriosis. Harris et al. excised appendices of abnormal appearance in women with pelvic endometriosis and chronic pelvic pain. Of 52 excised appendices, 39 (75%) had abnormal histopathology, including appendicitis or periappendicitis, fibrous obliteration, lymphoid hyperplasia, or carcinoid tumor. Endometriosis was confirmed by histopathology in 23% of these appendices. ²⁵ Berker et al. evaluated 231 women who underwent laparoscopic treatment of endometriosis. Appendectomy was performed if the appendix appeared to be abnormal, showing the presence of appendiceal adhesions, rigidity, hyperaemia, congestion, indurations, or implants of endometriosis (115 women). Histopathologic evidence of appendiceal endometriosis was encountered in 51 women (44.3%). ²² In another study, 4 of 5 women with appendices of abnormal appearance had appendiceal endometriosis (80%). ⁸

Table 1 shows the prevalence of appendiceal endometriosis in appendices of abnormal appearance among women with pelvic endometriosis and chronic pelvic pain.^8,22,25–28 The current review only included reports with more than 15 appendectomies. The prevalence of appendiceal endometriosis ranges between 9.5% and 44.3%. This wide range could be the result of the different perceptions of the surgeons with respect to the abnormal appendix. It is also possible that some authors performed appendectomy only in women with visible endometriosis.

Fayez et al. evaluated symptom improvement after appendectomy in 63 patients with pelvic pain and an appendix of abnormal appearance. Appendiceal endometriosis was found in 6 patients (9.5%). At a 1-year follow-up, 56 patients (89%) reported complete relief of pain. ²⁷ In another study, laparoscopic appendectomies for appendices of abnormal appearance in women with endometriosis and chronic pelvic pain was associated with complete pain relief in 60 of 62 patients (97%). ²⁸ It appears that most patients with chronic pelvic pain experience symptom relief after removal of an appendix with an abnormal appearance.

A few researchers have advocated elective appendectomies in women with chronic pelvic pain. Agarwala and Liu reported that a routine appendectomy was the only procedure associated with improvement in 91% of women with pelvic pain. These researchers included women with appendices of normal appearance. The prevalence of appendiceal endometriosis in this series was 4.4%. ¹⁷ Table 2 shows that the prevalence of appendiceal endometriosis among women with chronic pelvic pain ranges between 3.2 to 20%.^7,29–31

Surgical Technique

The technique of laparoscopic appendectomy has been previously described.^32–34 It involves lysis of adhesions (if present), mobilization of the appendix, and separation of the mesoappendix. The fecal content is pressed toward the tip of the appendix, using a grasper over an area of 2 cm from the cecum. ³⁴ Two Endoloop sutures (Ethicon Endo-Surgery Inc., Cincinatti, OH) are then placed around the base of the appendix next to each other. A third Endoloop suture is applied approximately 5 mm distal to the first 2 sutures. The appendix is cut between the second and the third sutures, using laparoscopic scissors. The stump of the appendix is then touched with a peanut gauze soaked with providone-iodine. Burying the stump by purse-string or Z suture is not necessary. ³⁵ Stapling devices such as an EndoGia (Mansfields, MA) or a multifilter stapler can also be used in a single motion, so the entire mesosalnpix and appendix can be divided.

Complications

The efficacy and safety of laparoscopic appendectomy are similar to that by laparotomy. Several studies have shown that the procedure does not add morbidity or increase the length of hospitalization.^32,36–37 The rates of postoperative wound infection and postoperative pain are less than those of open appendectomy.^38–40 Laparoscopic appendectomy during gynaecologic surgery does not increase postoperative complication rates or length of hospital stay.^41–42

Conclusions

Although there is no clear guideline regarding performing appendectomy in patients undergoing surgery for endometriosis, it appears that, regardless of the presence or absence of endometriosis, an appendectomy should be considered in women with chronic pelvic pain. This is especially important if the appendix appears to be abnormal. Patients should be counseled accordingly before surgery, and the surgeon should perform a thorough examination of the appendix during laparoscopy.