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Cited by 8Endometriosis Research and TreatmentGynecological conditions and treatmentsDiagnosis and treatment of tuberculosis

The appendix in endometriosis.

Open access
Guo, Cici, Chen, Michelle Zhiyun, Chiu, Tricia, Condous, George, Barto, Walid·2023·Australian and New Zealand Journal of Obstetrics and Gynaecology
DOI 10.1111/ajo.13730
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Abstract

In the most severe stage of endometriosis, Stage IV, intestinal involvement is common. The true prevalence of endometriotic disease of the appendix in this population is not well described. A macroscopically normal looking appendix may harbour endometriosis. Our study aims to assess the role of routinely performing appendicectomy in Stage IV endometriosis surgery, and the histopathological prevalence of true appendiceal endometriosis in this population. This is a retrospective study of women undergoing surgery for Stage IV endometriosis between 2018 to 2022 in a tertiary public hospital in New South Wales, Australia. Patient demographics, age and post-operative complications were retrospectively retrieved from hospital medical records. Inclusion criteria were women with Stage IV endometriosis who underwent routine appendicectomy as part of their endometriosis surgery. Exclusion criteria were women who did not have Stage IV endometriosis, those who had cancer surgery or emergency surgery for endometriosis. The primary outcome of this study was to determine the incidence of appendiceal endometriosis. Secondary outcomes included post-operative complications and length of stay. Sixty-seven patients were included. The mean age was 36 years. All patients also underwent bowel resection for colorectal endometriosis. There were 35.8% who had confirmed appendiceal endometriosis on histopathology. Post-operative complications included port site infections, colitis, urinary tract infection, and bowel leak. Appendicectomy in patients with severe endometriosis did not add additional morbidity. Concomitant appendicectomy should be considered in Stage IV endometriosis surgery given the high prevalence of disease.

Integrity signals

Registry

Crossref · 10.1111/ajo.13730

Cites

17 of 17 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

1 of 9 cited sources checked · 1 supported · 0 flagged

  • Premisecitation
    § DISCUSSION

    A visually normal appendix during surgery may reveal abnormal appendix histopathology.

    “Studies demonstrate that a visually normal appendix during surgery may in fact reveal abnormal appendix histopathology.18”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [18] 18. Nikou AF, Tenzel NS, Hua P et al. Appendectomy should Be per- formed during minimally invasive surgery for endometriosis. JSLS 2021; 25(1): e2020.00095. source
  • Findingown data
    § Abstract

    Among 67 women with Stage IV endometriosis who underwent appendicectomy as part of their endometriosis surgery, 35.8% (24/67) had confirmed appendiceal endometriosis on histopathology.

    “There were 35.8% who had confirmed appendiceal endometriosis on histopathology.”
    • Also stated in: § DISCUSSION · plain
      “This study found that the prevalence of appendiceal endometriosis in a cohort of 67 patients who underwent appendicectomy as part of excision of endometriosis surgery for rASRM Stage IV endometriosis was 35.8%.”
    Quote in the paperSubstantial claim
  • Findingown data
    § 4.4 days (1-24).

    None of the patients had appendiceal tumours on histopathology.

    “None of our patients had appendiceal tumours on histopathology.”
    Quote in the paperNot a substantial claim
  • Findingnone given
    § DISCUSSION

    All patients with confirmed appendiceal endometriosis reported pain symptoms pre-operatively.

    “All patients with confirmed appendiceal endometriosis reported pain symptoms pre-operatively.”
    Quote in the paperNot a substantial claim
  • Findingown data
    § DISCUSSION

    The minor complication rate was 6%, comprising one port site infection, two cases of colitis and one urinary tract infection.

    “We report a minor complication rate of 6%, which comprised one case of port site infection, two cases of colitis and one with urinary tract infection.”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 2
  • May combine two claims. 10
  • Classified as probably not a substantial claim. 11

  • The quote only partly states this claim.

    Findingown data
    § Abstract

    The mean length of post-operative hospital stay was 4.4 days (range 1-24).

    “Mean length of stay was 4.4 days.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 4.4 days (1-24).

    At 12 months follow-up, only two patients (8.3%) with confirmed appendiceal endometriosis reported ongoing pain symptoms, and none reported ongoing bowel symptoms.

    “Only two patients (8.3%) with appendiceal endometriosis reported ongoing pain symptoms following surgery and none reported ongoing bowel symptoms.”
    • Also stated in: § DISCUSSION · plain
      “At 12 months follow up post-operatively, only two patients (8.3%) reported ongoing pain symptoms and none reported ongoing bowel symptoms.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Abstract

    All patients in the cohort underwent bowel resection for colorectal endometriosis.

    “All patients also underwent bowel resection for colorectal endometriosis.”
    • Also stated in: § DISCUSSION · plain
      “All patients underwent some degree of bowel resection, either rectal shave (24%), disc resection (10%) or a segmental/low anterior resection (65.6%) for colorectal involvement, as well as removal of the appendix whether it appeared grossly diseased or not.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 4.4 days (1-24).

    Among patients with confirmed appendiceal endometriosis, pre-operative symptoms included dyspareunia (58%), dyschezia (58%), dysmenorrhoea (67%) and pelvic pain (67%).

    “Their pre-operative symptoms included pelvic pain (67%), dysmenorrhoea (67%), dyspareunia (58%), dyschezia (58%) and infertility (33%).”
    • Also stated in: § DISCUSSION · plain
      “Their symptoms included dyspareunia (58%), dyschezia (58%), dysmenorrhoea (67%) and pelvic pain (67%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § DISCUSSION

    At one year follow-up, 9% of patients reported persistent pain symptoms and 3% reported ongoing bowel symptoms.

    “At one year follow up post-operatively, only 9% of patients reported symptoms of persistent pain and only 3% of patients reported presence of ongoing bowel symptoms.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Abstract

    There were no post-operative anastomotic leakages or complications arising from performing appendicectomy itself.

    “There were no complications related to appendicectomy.”
    • Also stated in: § appendiceal endometriosis on histopathological assessment. · plain
      “There were no post-operative anastomotic leakages or complications arising from performing appendicectomy itself.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Abstract

    There were five post-operative complications (7.5%) in the cohort: one port site infection, two cases of colitis, one urinary tract infection, and one ureteric injury.

    “Postoperative complications included port site infections, colitis, urinary tract infection and ureteric injury.”
    • Also stated in: § appendiceal endometriosis on histopathological assessment. · plain
      “There were five post-operative complications (7.5%), including one port site infection, two with colitis, one with urinary tract infection and one case was complicated by ureteric injury.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § DISCUSSION

    All patients underwent removal of the appendix whether it appeared grossly diseased or not.

    “All patients underwent some degree of bowel resection, either rectal shave (24%), disc resection (10%) or a segmental/low anterior resection (65.6%) for colorectal involvement, as well as removal of the appendix whether it appeared grossly diseased or not.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data
    § DISCUSSION

    The major complication rate was 1.5% (one ureteric injury).

    “The overall major complication rate (1.5%) was low in this cohort.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data
    § DISCUSSION

    The distribution of bowel resection types was rectal shave 24%, disc resection 10%, and segmental/low anterior resection 65.6%.

    “All patients underwent some degree of bowel resection, either rectal shave (24%), disc resection (10%) or a segmental/low anterior resection (65.6%) for colorectal involvement, as well as removal of the appendix whether it appeared grossly diseased or not.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation
    § DISCUSSION

    Concurrent appendicectomy is a relatively safe procedure and could reduce the risk of the need for re-operation for appendiceal endometriosis in the future.

    “They argue that this is a relatively safe procedure and could reduce the risk of the need for re-operation for appendiceal endometriosis in the future.17”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] 17. Moulder JK, Siedhoff MT, Melvin KL et al. Risk of appendiceal en- dometriosis among women with deep-infiltrating endometriosis. Int J Gynaecol Obstet 2017; 139(2): 149-154. source

  • May combine two claims.

    Study design and conductreasoning
    § DISCUSSION

    The study was retrospective, so there is potential for confounding by unmeasured factors.

    “Due to the retrospective nature of the analysis, there is potential of confounding by unmeasured factors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § DISCUSSION

    The study number is low.

    “The number in the study is low, and results of this study represent a single centre and therefore may not be generalisable to other units who have varying experience in endometriosis surgery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given
    § DISCUSSION

    All symptom-related data collected were binary and severity was not assessed.

    “All symptom-related data collected were binary and severity was not assessed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § DISCUSSION

    Complete surgical excision of deep infiltrating endometriosis lesions results in significant reduction in pain.

    “This is consistent with existing literature demonstrating that complete surgical excision of deep infiltrating endometriosis lesions results in significant reduction in pain. 4”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] 4. Chopin N, Vieira M, Borghese B et al. Operative management of deeply infiltrating endometriosis: Results on pelvic pain symp- toms according to a surgical classification. J Minim Invasive Gynecol 2005; 12(2): 106-112. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § DISCUSSION

    Ross et al. reported no postoperative complications directly attributed to the performance of appendicectomy.

    “Ross et al. 10 also advocate for opportunistic appendicectomy at the time of surgery for endometriosis and reported no postoperative complications directly attributed to the performance of appendicectomy.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] 10. Ross WT, Chu A, Li L et al. Appendectomy in the surgical manage- ment of women with endometriosis and pelvic pain. Int J Gynecol Obstet 2021; 154: 526-531. source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data
    § Abstract

    Routine appendicectomy should be considered in a subset of Stage IV endometriosis patients with colorectal involvement undergoing surgery.

    “Laparoscopic appendicectomy can be safely performed at time of laparoscopic surgical excision of Stage IV endometriosis and should be routinely considered in a subset of Stage IV endometriosis patients with colorectal involvement undergoing surgery.”
    • Also stated in: § DISCUSSION · hedged
      “Given the low complication rate and the risk of missing macroscopically undetectable appendiceal endometriosis, tumours and other appendiceal pathology during surgery, there is an argument for concomitant appendicectomy at the time of minimally invasive surgery for severe Stage IV endometriosis.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The true prevalence of appendiceal endometriosis in Stage IV endometriosis is not well described.
    • Rests on an assumption: There are limited studies assessing outcomes or histopathological prevalence of appendiceal endometriomas in routine resection of the appendix in Stage IV endometriosis.
    • Rests on an assumption: There is a paucity of data to support routine appendicectomy in Stage IV endometriosis, and long-term outcomes after appendectomy for endometriosis are not well-described.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § DISCUSSION

    Moulder et al. reported that appendiceal endometriosis was present in 39% of women with deep infiltrating endometriosis undergoing gynaecologic surgery.

    “Moulder et al. 17 reported that appendiceal endometriosis was present in 39% of women with deep infiltrating endometriosis undergoing gynaecologic surgery.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] 17. Moulder JK, Siedhoff MT, Melvin KL et al. Risk of appendiceal en- dometriosis among women with deep-infiltrating endometriosis. Int J Gynaecol Obstet 2017; 139(2): 149-154. source

  • May combine two claims.

    Study design and conductreasoning
    § DISCUSSION

    The results represent a single centre and may not be generalisable to other units.

    “The number in the study is low, and results of this study represent a single centre and therefore may not be generalisable to other units who have varying experience in endometriosis surgery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § DISCUSSION

    Appendiceal endometriosis is reportedly higher in women with deep infiltrating endometriosis compared to women with superficial endometriosis.

    “Appendiceal endometriosis is reportedly higher in women with deep infiltrating endometriosis compared to women with superficial endometriosis.16,17”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [16] 16. Setälä M, Savolainen H, Kössi J et al. Deeply infiltrating disease in surgically treated endometriosis patients. Acta Obstet Gynecol Scand 2011; 90: 468-472. source
    • cites [17] 17. Moulder JK, Siedhoff MT, Melvin KL et al. Risk of appendiceal en- dometriosis among women with deep-infiltrating endometriosis. Int J Gynaecol Obstet 2017; 139(2): 149-154. source
20 of 20

  • The paper relies on this without support.

    The true prevalence of appendiceal endometriosis in Stage IV endometriosis is not well described.

    “The true prevalence of endometriotic disease of the appendix in this population is not well described.”

  • The paper relies on this without support.

    There are limited studies assessing outcomes or histopathological prevalence of appendiceal endometriomas in routine resection of the appendix in Stage IV endometriosis.

    “There are limited studies that assess outcomes or histopathological prevalence of appendiceal endometriomas in routine resection of the appendix in Stage IV endometriosis.”

  • The paper relies on this without support.

    There is a paucity of data to support routine appendicectomy in Stage IV endometriosis, and long-term outcomes after appendectomy for endometriosis are not well-described.

    “Currently, there is a paucity of data to support routine appendicectomy in Stage IV endometriosis and the long-term outcomes after appendectomy for endometriosis are still not well-described in the literature.”
3 of 3

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Previous-surgery percentage is overstated

    Minor

    Table 1 reports previous endometriosis surgery in 25 of 67 patients. That is 37.3%, which rounds to 37%, not the reported 38%.

    Reported 38 · recomputed 37.313433

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Rokitansky CV, 1860, Ueber Uterusdrusen‐neubildung in Uterus and Ovariul Sarcomen, Z Gesellschaft Aerzte Wien, 16, 577

Cited by

Sorted by citations

Related

Authors
Guo, C., Chen, M. Z., Chiu, T., Condous, G., & Barto, W.
Affiliations
  • Nepean Hospital (AU)
  • The University of Sydney (AU)
Corresponding author
Guo, Cici
ORCID
Venue
Australian and New Zealand Journal of Obstetrics and Gynaecology
Publisher
Wiley
Published
2023-07-10
Volume
63
Issue
6
Pages
792-796
ISSN
  • 0004-8666 (ISSN-L)
  • 1479-828X
DOI
10.1111/ajo.13730
OpenAlex
W4383700655
Semantic Scholar
f5b308fc7502ce436a356f5fa75e70717ccda58f
Cited by
8
References
17
Citations by year
2026: 1 · 2025: 2 · 2024: 4 · 2023: 1
FWCI
1.92
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Australian and New Zealand Journal of Obstetrics and Gynaecology (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
  • Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
  • Health Sciences › Medicine › Surgery › Diagnosis and treatment of tuberculosis
Keywords
appendiceal endometriosis, stage IV endometriosis, appendectomy, colorectal endometriosis, intestinal endometriosis, postoperative complications, laparoscopic surgery, length of hospital stay
MeSH terms
Adult, Appendectomy, Appendix, Endometriosis, Female, Humans, Laparoscopy, Postoperative Complications, Retrospective Studies, Colorectal Neoplasms, Treatment Outcome

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