Endometriosis and the Appendix - Incidence and Pathologic Analysis
Condition: Endometriosis of the Appendix
MeSH terms: Endometriosis
Study type: Interventional

Summary: 
      There is great variation seen in the incidence of appendiceal endometriosis. The variation is
      most likely multifactorial, but method with which the specimen is examined may play a role.
      If analysis using more cuts is used, appendiceal endometriosis may be diagnosed at a higher
      rate.
    

Detailed description: 
      Endometriosis is the presence of endometrial and stromal glands at extrauterine sites. One of
      the extrauterine sites that may be involved is the GI tract. The extent of bowel involvement
      can range from an incidental spot on the serosa to ectopic endometrium causing a bowel
      obstruction. The rate at which the bowel is involved ranges from 3-34%, as noted by Gustofson
      in a literature review published in Fertility and Sterility. The symptomatology of GI
      endometriosis can be vast. Presenting as cyclic or chronic pelvic pain, right lower quadrant
      pain, melena, GI upset/pain, and as serious as intussusception and appendicitis.

      The incidence with which endometriosis is identified in the appendix potentially causing the
      complications that were noted, is reported as a wide range, 1-22%. The low of 1% is reported
      in two separate studies. The first, by Harper and Soules, published in the International
      Journal of Gynecology and Obstetrics, and the second, by Weed and Ray, in Obstetrics and
      Gynecology. The highest rate of 22% was reported by Berker and colleagues in the Journal of
      Minimally Invasive Gynecology. Noting the possibility of greater than 20% of individuals with
      endometriosis having appendiceal involvement, incidental appendectomy may be of benefit.

      The American College of Obstetrics and Gynecology (ACOG) released a Committee Opinion on
      incidental appendectomy that was reaffirmed in 2012. These are the guidelines that are
      followed by gynecologists today. ACOG notes that women 35years of age and younger benefit the
      most from elective coincidental appendectomy. Others who may be of significant benefit are
      those patients with a complicated differential, those in who chemotherapy is anticipated, and
      those who are expected to have extensive post-op adhesions.

      ACOG goes on to note that the decision to perform an appendectomy at the time of a
      gynecologic procedure should be based on individual scenarios after the risks and benefits
      are discussed with the patient. The procedure has a low risk of morbidity, and if there is
      reasonable probability the benefits outweigh the risks, based on age or history, elective
      coincidental appendectomy during primary gynecologic procedure may be appropriate.

      Considering the variation seen in publications, the rate of diagnosis that the surgeon may
      find may be broad. The reason for this variation, though, is under speculation. Although, it
      is most likely multifactorial, the method with which the specimen is analyzed may play a
      role. In all of the methods sections in the above mentioned research papers and others
      regarding this topic, description of the technique used for pathologic analysis was not
      available. Here at Penn State Hershey Medical Center, a 3 slice method is employed. A cut is
      made at the proximal and distal end, and a third cut in the center. If this method is
      modified to include more cuts, the hypothesis is that endometriosis of the appendix will be
      diagnosed at a higher rate. Appendix specimens will be collected as indicated, following ACOG
      recommendations. After removal of the appendix patient's will be consented to allow the
      second pathologic analysis. Time frame for collection and second analysis will be
      approximately 12 months, the anticipated time to obtain 100 specimens.
    

Intervention name(s): Modified Pathologic Analysis
Intervention type(s): Other
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Primary purpose: Diagnostic