Issues in the treatment of patients with endometriosis

1. About the destruction of the vermiform process cecum.
Opinions about how to deal with vermiform process of the cecum is controversial. So, C. Williams (1975) believes that, in addition to removing foci of endometriosis of the ovaries, the surrounding tissues and organs should be the neurectomy, plastic fallopian tubes and appendectomy. In the author's opinion, such a volume of operations can significantly reduce the activity of adhesions in the postoperative period. It seems that each of these interventions should have certain indications. The combination of gynecological surgery with removal unchanged vermiform process can be indifferent.
Later T. Williams and J. Pratt (1977), analyzing the frequency and prevalence of endometriosis 1000 laparotomy, found that in 10-15 % of women with endometriosis captures and vermiform process cecum. Our clinical material confirms the possibility of the involvement process in cicatricoadhesive process. This usually occurs when endometriosis right ovary. In addition, much less in the vermiform Appendix, you can find macroscopically visible foci of endometriosis various sizes (from 1-2 up to 10 mm in diameter). Defeat him endometriosis can occur due to regurgitation of endometrial implants contained in menstrual blood, organs of small pelvis and adjacent intestine with appropriate endocrine and immune disorders. A similar provision is created when spontaneous perforation of endometrioid cystadenoma ovary. In the latter case the body has the appropriate hormonal and immune conditions (background). In addition, it may result chervenakovo process endometriosis after his involvement in adhesions with the right ovary containing endometrioid enable, or lesions pozavcherashny localization and less frequently - in the front wall of the rectum.
Whenever the Genesis of the pathological process in the vermiform Appendix develop changes, characteristic of chronic inflammation (hardening of its walls with more or less pronounced vascular injection, cicatricoadhesive preprocessor). The presence of macroscopically visible lesions brown and blue in sklerozirovanie wall allows you to make a correct diagnosis. The part of the lesions can be detected only by histological examination of the remote process.
Retrospective analysis of the features of the clinical picture of endometriosis of the Appendix shows that in periods of paroxysmal pain in the abdomen body temperature was up to subfebrile level or remained normal. In the hemogram at this time were observed changes characteristic of acute appendicitis. The episodic pain in the abdomen time coincided with the monthly or was observed shortly after the end of the month, although not every cycle. All this, taken together, and detection of gynecologists painful conglomerate right of the uterus in combination with instructions on chronic adnexitis in history, apparently kept surgeons from appendectomy.
It seems appropriate individual decision of a question after you perform gynecological part of the transaction subject to the following provisions. The presence of even small macroscopically visible foci of endometriosis in the process is an indication for its removal. Exactly should I do if the process was deservirea in the process of separating it from binding with the uterus or its appendages.
Detect anatomical changes characteristic of chronic appendicitis, especially when appropriate clinical picture, from our point of view, is an indication for its removal.
Atypical located process (retrocasino or along the upward part of the colon, also fixed in subhepatic region) with signs of chronic inflammation also be deleted after the operation on the genitals. If gynecologist not able to use the technique of such operations, it is necessary to invite the surgeon.
The question about appendectomy with signs of chronic inflammation of the Appendix surgeons is solved differently. Often surgeons blame gynecologists for the deletion of chronically inflamed Appendix. However, we should not forget about the peculiarities of manifestations of acute inflammatory reaction in any organ, including in the vermiform Appendix blind gut, hormonal therapy progestin conducted before and after surgery for endometriosis, namely, acute inflammatory reaction is reduced (proceeds erased, without severe pain, a significant increase in body temperature and a shift in the hemogram, characteristic of acute appendicitis). And this is due to immunosuppressive action of progestins.
A characteristic picture of acute appendicitis, but not always, only with the development of gangrene and destruction process. The postoperative period in such situation is accompanied by the development of inflammatory complications and peritonitis. And then the use of progestins in complex fixing therapy for endometriosis should be suspended.
Comparison of the above provisions for and against appendectomy in the presence of a chronic inflammation of the vermiform process, from our point of view, should sway the decision in favour of its deletion.
If the process is not changed, then no reason for his removal is not. Therefore, we cannot support the recommendations about removing unchanged vermiform process in surgery for endometriosis.
Of course, subject to deletion process with signs of acute inflammation caused by suppuration endometrioid ovarian cyst (secondary acute appendicitis). It is impossible not to take into consideration the common lymphatic system right of the uterus and the vermiform process cecum. Good access and a tranquil environment with sufficient relaxation and skills of the surgeon-gynecologist to make it easier, especially in obese women, as compared with the period, when will flegmonozna inflammation and destruction of the process.

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