Distinct molecular targets of ProEGCG from EGCG and superior inhibition of angiogenesis signaling pathways for treatment of endometriosis

Endometriosis is a common chronic gynecological disease with endometrial cell implantation outside the uterus.Angiogenesis is a major pathophysiology in endometriosis.Our previous studies have demonstrated that the prodrug of epigallocatechin gallate(ProEGCG)exhibits superior anti-endometriotic and anti-angiogenic effects compared to epigallocatechin gallate(EGCG).However,their direct binding targets and underlying mechanisms for the differential effects remain unknown.In this study,we demonstrated that oral ProEGCG can be effective in preventing and treating endometriosis.Additionally,1D and 2D Proteome Integral Solubility Alteration assay-based chemical proteomics identified metadherin(MTDH)and PX domain containing serine/threonine kinase-like(PXK)as novel binding targets of EGCG and ProEGCG,respectively.Computational simulation and BioLayer interferometry were used to confirm their binding affinity.Our results showed that MTDH-EGCG inhibited protein kinase B(Akt)-mediated angiogenesis,while PXK-ProEGCG inhibited epidermal growth factor(EGF)-mediated angiogenesis via the EGF/hypoxia-inducible factor(HIF-1a)/vascular endothelial growth factor(VEGF)pathway.In vitro and in vivo knockdown assays and microvascular network imaging further confirmed the involvement of these signaling pathways.Moreover,our study demonstrated that ProEGCG has superior therapeutic effects than EGCG by targeting distinct signal transduction pathways and may act as a novel antiangiogenic therapy for endometriosis.

Can Tibetan medicine Honghua Ruyi pills relieve endometriosisassociated dysmenorrhea?Protocol for a randomized placebocontrolled trial

Objective:To provide high-quality clinical evidence of the efficacy of Tibetan medicine Honghua Ruyi(HHRY)pills for endometriosis-associated dysmenorrhea.Methods:This study constitutes a multicenter,randomized,double-blind,placebo-controlled trial encompassing a three-menstrual cycle intervention followed by a three-menstrual cycle follow-up period.A total of 164 eligible females with endometriosis-associated dysmenorrhea were randomly divided into HHRY pills and placebo groups in a 1:1 ratio.The primary outcome included dysmenorrhea symptoms assessed using Visual Analog Scale(VAS)scores and quality of life,whereas the secondary outcome measures included the maximum VAS for non-menstrual pelvic pain,duration of pain episodes(in days),frequency and quantity of the consumption of ibuprofen sustained-release capsules(or other non-steroidal anti-inflammatory drugs),and days off work/study for staff/student due to dysmenorrhea,ovarian cyst,and/or pelvic nodule size.The safety was monitored throughout the treatment period.All the analyses were based on the intention-to-treat principle.For continuous outcomes,simple or multiple linear regressions were used to estimate the differences between the HHRY pills and placebo groups,with categorical data expressed as the number and percentage of occurrences.Differences were compared using the chi-square test or Fisher's exact test.The predefined analysis was adjusted for concomitant treatment,a variable considered to be associated with outcomes but unaffected by treatment allocation.Estimates of treatment effects were reported with 95%confidence intervals.Two-tailed P values≤.05 were considered statistically significant.Conclusion:Positive results from this trial,upon completion would provide robust evidence for the efficacy and safety of HHRY pills in treating dysmenorrhea in patients with endometriosis.

Endometriosis beyond the Pelvis: A Case Series of Cutaneous Endometriosis and Literature Review

Introduction: Cutaneous endometriosis is an uncommon but well-known skin disorder that represents about 0.5% to 1% of all endometriosis. The objective of this case series is to report clinical presentation, diagnosis, and management of various forms of cutaneous endometriosis. Material and Methods: It was an observational, retrospective and descriptive review of cases presenting with cutaneous endometriosis among Cameroonian women managed at the gynaecological outpatient department of Yaounde Gynaeco-Obstetric and Pediatric Hospital. All the following parameters were analysed: age, parity, previous pelvic surgery, presenting symptoms and duration, associated symptoms, localizations, imaging, size of the lesion, other localization of endometriosis, management and histopathological results. Results: we reported 4 cases of cutaneous endometriosis, with 3 umbilical endometriosis and 1 abdominal scar endometriosis. Patient age ranged from 28 to 39 years with an average of 33 years. All patients described infertility (two primary and two secondary) and two had a history of abdominal surgery. All patients presented local cyclical signs such as pain, swelling, color change and bleeding. The duration of symptoms varied from 2 to 3 years and the size of lesions ranged from 2 to 3.5 cm for umbilical lesions and was 9 cm for abdominal scar endometriosis. In all cases, no imaging was required for the diagnosis, which was suspected on the basis of patient’s history and the cyclical nature of local signs, followed by wide surgical excision and confirmation on histopathology. Conclusion: Cutaneaous endometriosis is a rare benign condition. Umbilical endometriosis seems to be the main cutaneous localization and can be described as primary or secondary. Even if its diagnosis must be confirmed by histopathology, it should be considered in patient with cutaneous cyclic signs such as pain, swelling or bleeding with or without history of abdominal surgery.

Immune pathway through endometriosis to ovarian cancer

Endometriosis is an estrogen-dependent inflammatory disease,defined by the presence of functional endometrial tissue outside of the uterine cavity.This disease is one of the main gynecological diseases,affecting around 10%-15%women and girls of reproductive age,being a common gynecologic disorder.Although endometriosis is a benign disease,it shares several characteristics with invasive cancer.Studies support that it has been linked with an increased chance of developing endometrial ovarian cancer,representing an earlier stage of neoplastic processes.This is particularly true for women with clear cell carcinoma,low-grade serous carcinoma and endometrioid.However,the carcinogenic pathways between both pathologies remain poorly understood.Current studies suggest a connection between endometriosis and endometriosis-associated ovarian cancers(EAOCs)via pathways associated with oxidative stress,inflammation,and hyperestrogenism.This article aims to review current data on the molecular events linked to the development of EAOCs from endometriosis,specifically focusing on the complex relationship between the immune response to endometriosis and cancer,including the molecular mechanisms and their ramifications.Examining recent developments in immunotherapy and their potential to boost the effectiveness of future treatments.

Difficulties Faced by Physicians in the Diagnosis of Endometriosis in the Brazilian Public Health System

Endometriosis is a clinical and recurrent condition characterized by the presence of functional endometrial tissue outside the uterine cavity and myometrium. It is estimated that 6% to 10% of women of reproductive age, 50% to 60% of adolescents and adults with pelvic pain, and up to 50% of women with infertility are pregnant from the condition. However, this proportion tends to be even greater due to the difficulty in diagnosing it: because it presents different symptoms, lack of information from health professionals, and a high-cost diagnostic test. Another aggravating factor is the average time from the onset of symptoms to the medical diagnosis, which even today ranges from five to ten years;this delay has consequences for disease progression, as it prevents early treatment, which is important for improving pain levels and physical and psychological well-being. Aware of these mishaps, it is therefore important to assess the difficulties faced by doctors in the diagnosis of endometriosis in the public health system, in Brazil, the Unified Health System (SUS). With this purpose, a cross sectional was carried out, developed in the virtual environment using traffic in Google forms, with the difficulties quantified in the Likert scale. Participating physicians pointed out a medium difficulty for patients with endometriosis to access the consultation (58%) and moderate difficulty (52%) to perform an ultrasound examination;also signaled great difficulty in performing magnetic resonance imaging (77%) and laparotomy (61%) in these patients. It is hoped that knowledge about the difficulties faced by physicians in the diagnosis of endometriosis in the SUS will give these physicians a voice and corroborate, even if minimally, so that there is more research that provokes the search for these difficulties, in order to improving the quality of life of these women.

Diagnosis Delay and Assessment of the Quality of Life of Patients with Endometriosis Using the Endometriosis Health Profile 5 Questionnaire in a Sub-Saharan Population

Context: Endometriosis is a pathology that directly affects the daily lives of women with frequent impairment of their quality of life. In our environment, medical, socio-cultural, financial factors and factors related to the organization of the health care system greatly delay its diagnosis. The objectives of the present study were to determine the diagnosis delay and to assess the quality of life before surgery of women with endometriosis using the specific Endometriosis Health Profile 5 (EHP-5) questionnaire. Methods: We carried out a descriptive, observational, retrospective study in 8 medical centers in the City of Kinshasa, from January 2019 to October 2022. A total of 80 women with endometriosis confirmed by laparoscopy (16 diagnostic and 64 operative laparoscopies) and histopathology were interviewed. We used the revised American Society for Reproductive Medicine (rASMR) classification, the Endometriosis Fertility Index (EFI) score was calculated for infertile women and the EHP-5 questionnaire to assess quality of life. Our data was entered and analyzed using Statistical Analysis Software 16.1 (STATA 16.1). Results: Diagnosis delay of endometriosis was on average 12 ± 4.3 years. The overall mean EHP-5 score of all patients showed a severe deterioration in quality of life (604 ± 235). A negative relationship was observed between the age of the patient, the diagnostic delay, and the alteration of the quality of life in patients over 36 years old and those with about 11 years of diagnostic delay presenting the slight alteration. Patients with a high social level had very severe quality impairment. Women on hormonal treatment, those with a history of pregnancy, childbirth, miscarriage and abortion had a slight and significant deterioration in quality of life (p 0.05). Conclusion: Despite some limitations, our preliminary study highlights that in sub-Saharan Africa, the diagnosis of endometriosis is delayed and associated with a severe alteration in quality of life. Moreover, diagnosis of endometriosis seems to be restricted to women with high social levels. Therefore, further efforts are required to develop a health policy to decrease delay for diagnosis with potential benefits on symptoms, quality of life, fertility while limiting stigma and psychological effects of this debilitating pathology.

Identification of EML4 as a key hub gene for endometriosis and its molecular mechanism and potential drug prediction based on the GEO database

Objective:Key genes were screened to analyze molecular mechanisms and their drug targets of endometriosis by applying a bioinformatics approach.Methods:Gene expression profiles of endometriosis and healthy controls were obtained from the Gene Expression Omnibus database.Significant differentially expressed genes were screened using the limma package.Correlation pathways were screened by Spearman correlation analysis on the echinoderm microtubule-associated protein-like 4(EML4)and enrichment in endometriosis pathways and estimated by the GSVA package.Immune characteristics were assessed by the“ESTIMATE”R package.Potential regulatory pathways were determined by enrichment analysis.The SWISS-MODE website was used in homology modeling with EML4 and EML4 protein activity was predicted.VarElect was employed in molecular docking for screening potential compound inhibitors targeting endometriosis.Results:Ten endometriosis and 10 normal samples were included.EML4 was significantly upregulated in endometriosis(p<0.05).Thirty significantly correlated pathways involving 18 positive and 12 negative correlations,including GLYCOSAMINOGLYCAN_BIOSYNTHESIS_HEPARAN_SULFATE and GLYCOSPHINGOLIPID_BIOSYNTHESIS_GANGLIO_SERIES were screened between EML4 and endometriosis.Immunocorrelation analysis showed a significant difference in immune-related pathways in endometriosis and normal samples(p<0.05).In endometriosis,EML4 was associated with T-cell CD4 resting memory,activated mast cells,plasma cells,activated NK cells,M2 macrophages,and follicular helper T cells(p<0.05).Molecular docking identified five potential inhibitors of EML4,and compound DB05104(asimadoline)bound well to EML4 protein to exert its physiological effects.Conclusion:Differential gene expression and immune correlation analyses revealed that EML4 may affect endometriosis through multiple targets and pathways,the mechanism of which involved immune cell activation and infiltration.Molecular docking and dynamics simulation verified DB05104 as a potential inhibitor of EML4 and a powerful target for endometriosis treatment.

Epidemiological Profile and Location of Lesions According to #ENZIAN of Patients Operated on for Endometriosis in a Public Endoscopic Surgery Centre, Yaounde, Cameroon

Introduction: Endometriosis is a chronic disease affecting approximately 10% of women. Our aim was to describe the epidemiological profile, clinical presentation and location of lesions in patients operated on for endometriosis. Methodology: We conducted an analytical cross-sectional study with retrospective data collection over a period of 05 years from 1 January 2017 to 31 March 2022. Our study population consisted of women who had undergone laparoscopy for endometriosis. Data analysis was performed using SPSS software version 23.0. Results: In total we included 159 patients who had undergone laparoscopy for endometriosis. The mean age was 32.9 ± 5.9 years, most of whom were nuligravida 61.6% (n = 99). Infertility was the most frequent reason for consultation, accounting for 72.3% (n = 115), followed by dysmenorrhoea in 60.8% (n = 96) of cases and chronic pelvic pain in 37.7% (n = 60). In addition, 46 (28.9%) patients complained of deep dyspareunia, 17 (10.7%) of dyschezia and nine (5.7%) of dysuria. Magnetic Resonance Imaging (MRI) was used in one patient. Diagnostic laparoscopy was performed directly in 77 (48.4%) patients. The lesions were multifocal, according to the #ENZIAN classification nomenclature. Tubal lesions were most frequently found 107 (67.3%) on the left, followed by compartment B (uterosacral ligaments, cardinal ligaments and lateral pelvic wall) 49.7% (n = 79), and endometriomas 40.9% (n = 65). Conclusion: Women operated on for endometriosis were of a more advanced age, and predominantly nulliparous. Infertility was the most frequent reason for consultation and tubal location most frequently encountered for superficial lesions and compartiment B for deep lesions according to #ENZIA.

Rapidly growing extensive polypoid endometriosis after gonadotropin-releasing hormone agonist discontinuation:A case report

BACKGROUND Polypoid endometriosis(PEM)is a rare and unique type of endometriosis.To date,no article has provided a systematic report of this disease.The current article provides a complete report on rare PEM based on ultrasound,magnetic resonance imaging,intraoperative findings and postoperative pathology data.CASE SUMMARY A 38-year-old female patient was admitted to our hospital after complaining of“vague pain in the right lower quadrant with an aggravated menstrual period for 8 mo”.The patient underwent laparoscopic exploratory surgery on January 7,2022.The postoperative pathology revealed extensive PEM.CONCLUSION PEM is a type of endometriosis that is a benign disease but has biological properties similar to malignant tumours.

Traditional Chinese medicine for the treatment of endometriosis: a comprehensive-review of treatment mechanisms

The study aims to reveal the mechanism of traditional Chinese medicine in the treatment of endometriosis and provide support for further research on traditional Chinese medicine and its active ingredients.The literature survey was conducted using PubMed,Web of Science,CNKI and other databases with“endometriosis”,“Chinese medicine”,“Chinese herbal medicine”and“natural plants”as the main keywords.Traditional Chinese medicine can exert their therapeutic effects on endometriosis by inhibiting inflammation through multiple pathways and multiple targets,regulating cell proliferation and apoptosis,angiogenesis,cell adhesion and oxidative stress.Traditional Chinese medicine can intervene in endometriosis in multiple ways and with multiple targets.In-depth study of Chinese medicine for endometriosis can provide new ideas for exploring the pathogenesis of endometriosis and developing new drugs.

罕见抗-Di^(b)致严重胎儿新生儿溶血病的实验室检测与相关研究

目的对1例高频抗体导致的胎儿新生儿溶血病(hemolytic disease of the fetus and newborn,HDFN)进行检测、鉴定及配血。方法对患儿进行新生儿溶血试验,对母亲进行血清学意外抗体鉴定,并对母亲红细胞进行常见高频抗原鉴定;对检出抗体进行IgG分型检测,并用流式细胞术进行单核细胞体外吞噬致敏红细胞试验,以检测抗体相关的吞噬率;对患儿母亲、父亲及舅舅进行相关红细胞血型基因测序;利用稀释的母亲血浆和抗人球卡法,在献血者中进行大规模相合血液的筛选。结果产妇鉴定为Di(b-)稀有血型,产生了抗-Di b(效价512)并导致了严重的HDFN;抗-Di b亚型分型为IgG1和IgG2型,单核细胞体外吞噬效率为88.83%(74.7/84.09);产妇亲属中没有相合献血者,后续从5520名献血者中筛选到2例Di(b-)相合血液,患儿接收输血治疗后康复出院。后续在51334名献血者中筛查到17名Di(b-)献血者,该数据表明Di(b-)在广州地区献血者中的分布频率约为三千分之一(0.033%,17/51334)。结论综合利用血型血清学及分子生物学方法诊断了抗-Di b所致的严重HDFN,建立了1种有效大规模筛查Di(b-)稀有血型的方法并找到相合血液,为建立Di(b-)稀有血型库奠定了基础。

4DI110型空压机的技术改造与操作优化

文章通过介绍新引进的4DI110型离心式空压机(以下简称“空压机”)试运行阶段开始以来的运行情况和气温变化对空压机出口流量造成的影响,分析空压机出口流量随气温变化而变化的规律,指出空压机防喘阀V3004阀不能自动调节出口压力,影响空分装置工况的稳定。为实现空压机出口压力的稳定,对其防喘阀V3004阀采取增设自动旁路阀V3008阀的技术改造,同时优化和完善相关逻辑控制并阐述了空压机经技术改造后的操作优化和取得的实际效果。

Intrahepatic endometriosis as differential diagnosis: Case report and literature review

Intrahepatic endometriosis is one of the rarest forms of atypical endometriosis; only eighteen cases have been reported in the English literature. We describe the case of a 32-year-old woman, who presented with persistent, non-cyclical upper right quadrant abdominal pain, a central liver cyst, and no history of endometriosis. Three years previous, she was diagnosed with an intrahepatic cyst. The lesion progressed and two laparoscopic deroofing-operations were performed, yet the diagnosis of intrahepatic endometriosis was never reached. She presented in our clinic with further progress of the cyst as well as obstruction of the intrahepatic biliary system. The magnetic resonance imaging showed a 9.5 cm × 12 cm, lobulated intrahepatic cyst. We performed an ultrasonic pericystectomy. Immunostaining confirmed intrahepatic endometriosis. Only one of the previously described eighteen patients with intrahepatic endometriosis presented with cyclical pain in the upper right abdominal quadrant accompanying menstruation. This lack of a "typical" clinic makes it challenging to diagnose extragonadal endometriosis without histopathology. A previous history of endometriosis was described in only twelve cases, thus the diagnosis of this condition should not be limited to patients with a known history of endometriosis. Six of 18 patients were postmenopausal, demonstrating this condition is not limited to women of reproductive age. A preoperative diagnosis was only reached in seven of the previously described cases, highlighting the importance of preoperative biopsies. Yet due to the potential adverse effects, a transhepatic biopsy must be discussed individually. Although rare, intrahepatic endometriosis should always be considered as a differential diagnosis in women with recurrent hepatic cysts, regardless of age or previous medical history. In such cases, histology is essential and a pericystectomy should be performed as standard of care.

Hupo powder promotes autophagy of menstrual blood-derived stem cells from patients with endometriosis

Objective:To explore the effect of Hupo powder(HP)on autophagy in menstrual blood-derived stem cells(MenSCs)with endometriosis(EMT).Methods:EMT MenSCs(E-MenSCs)and healthy MenSCs(H-MenSCs)were isolated from the menstrual blood of patients with EMT and healthy female participants,respectively.We identified their stem cells’characteristics via adipogenic and osteogenic differentiation.Twelve male SpragueeDawley rats received 0.9% NaCl and HP-dispensing granules by gastric irrigation to prepare blank serum and medicated serum,respectively.We used serum concentrations of 5%,10%,and 20%,each at administered times of 12,24,and 48 h to select the best condition.These cells were divided into three groups:blank serum of the control group,blank serum of the model group,and medicated serum of the HP group.H-MenSCs were used in the control group,while E-MenSCs were used in the model and HP groups.We analyzed cell viability using a cell counting kit-8 assay,observed cell morphology,evaluated the amounts of auto-phagosomes and autolysosomes by transmission electron microscopy,and detected the protein expression of autophagy markers(LC3-II and Beclin1)by Western blot.Results:E-MenSCs and H-MenSCs became long fusiform with a diffuse radial pattern,forming lipid droplets and calcium nodules after adipogenic and osteogenic differentiation.We then used the best conditiond 20% serum and 48 hdfor the subsequent experiments.In contrast to the model group,the HP group exhibited lower cell viability(=0.007),larger amounts of autophagosomes and autolysosomes(P<0.001 and P=0.001,respectively),and higher expression of LC3-II and Beclin1(P=0.021 and P=0.019,respectively).Conclusion:Hupo powder can promote autophagy in E-MenSCs,which might be one of the mechanisms underlying its therapeutic effects.

Preoperative rectosigmoid endoscopic ultrasonography predicts the need for bowel resection in endometriosis

BACKGROUND Rectosigmoid endometriosis is an underdiagnosed disease responsible for abdominal pain, transit disorders and rectal bleeding. Two surgical approaches,rectosigmoid bowel resection(segmental or patch) or intramuscular layer dissection(shaving), are available.AIM To assess whether the lesion features observed via preoperative rectosigmoid endoscopic ultrasonography(RS-EUS) might predict the need for bowel resection.METHODS This multicentric retrospective study was conducted on patients with rectosigmoid endometriosis who underwent a curative surgical procedure,evaluated by RS-EUS performed by two trained operators, between January 2012 and March 2018. A univariate statistical analysis was performed on nodules' RSEUS features(thickness, width, infiltration of the submucosae, presence of a bump into the digestive lumen and presence of multiple rectosigmoid localizations). A multivariate logistic regression was then performed on the significant results.RESULTS Of the 367 patients, 73 patients with rectosigmoid endometriosis were evaluated by RS-EUS and underwent rectosigmoid surgery. After the univariate analysis was completed, thickness, width and infiltration of the submucosae were identified as potential predictive factors for bowel resection. In a multivariate logistic regression model, only thickness appeared to be a significant [odds ratio(OR) = 1.49, 95% confidence interval(CI): 1.04-2.12, P = 0.028] predictive factor for bowel resection. Receiver operating characteristic analysis performed showed that a thickness over 5.20 mm might be used as cut-off with a sensitivity of 76%, a specificity of 81%, and an area under carve = 0.82. The cut-off values for 100%sensitivity and 100% specificity were 0.90 mm and 10.00 mm, respectively. A trend concerning width to predict the need for resection was also observed(OR1.12, 95%CI: 1.00-1.26, P = 0.054)CONCLUSION The presence of a rectosigmoid nodule of endometriosis greater than 5.20 mm thick on RS-EUS might predict the need for bowel resection.

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM:To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis.METHODS:This prospective observational study was performed between September 2011 and July 2014.Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included.The study was approved by the local ethics committee and written informed consent was obtained in all cases.Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques.Laparoscopy was performed within4 wk of colonoscopic examination.All hypothetical colonoscopy findings(eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis)were compared with laparoscopic and histological findings.We calculated the sensitivity,specificity,positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis.RESULTS:A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy andsurgical intervention were included in our analysis.In 76 of the women(43.6%),intestinal endometrial implants were found at surgery and histopathological examination.Specifically,38 of the 76 lesions(50%)were characterized by the presence of serosal bowel nodules;28 of the 76 lesions(36.8%)reached the muscularis layer;8 of the 76 lesions(10.5%)reached the submucosa;and 2 of the 76 lesions(2.6%)reached the mucosa.Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the174(4%)examinations.Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women(92.1%).A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement,in 3of 8 cases(37.5%)of submucosal involvement,in no cases of muscularis layer involvement and in 1 of 38cases(2.6%)of serosa involvement.The sensitivity,specificity,positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%,98%,85%and 58%,respectively.CONCLUSION:Being an invasive procedure,colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.

Intestinal endometriosis:Diagnostic ambiguities and surgical outcomes

BACKGROUND Endometriosis is a common disease for women of reproductive age. However,when it involves intestines, it is difficult to diagnose preoperatively because its symptoms overlap with other diseases and the results of evaluations can be unspecific. Thus it is important to know the clinical characteristics of intestinal endometriosis and how to exactly diagnose.AIM To analyze patients in whom intestinal endometriosis was diagnosed after surgical treatments, and to evaluate the clinical characteristics of preoperatively misdiagnosed cases.METHODS We retrospectively reviewed the pathologic reports of 30 patients diagnosed as having intestinal endometriosis based on surgical specimens between January2000 and December 2017. We reviewed their clinical characteristics and surgical outcomes.RESULTS Twenty-three(76.6%) patients showed symptoms associated with endometriosis,with dysmenorrhea being the most common(n = 9, 30.0%). Thirteen patients(43.3%) had a history of pelvic surgeries. Ten patients(33.3%) had a history of treatment for endometriosis. Only 4 patients(13.3%) had a diagnosis of endometriosis based on endoscopic biopsy findings. According to preoperative evaluations, 13 patients(43.3%) had an initial diagnosis of pelvic endometriosis and 17 patients(56.6%) were misdiagnosed as having other diseases. The most common misdiagnosis was submucosal tumor in the large intestine(n = 8, 26.7%),followed by malignancies of the colon/rectum(n = 3, 10.0%) and ovary(n = 3,10.0%). According to the Clavien-Dindo classification, 5 complications were grade I or II and 2 complications were grade IIIa. The median follow-up period was 26.9(0.6-132.1) mo, and only 1 patient had a recurrence of endometriosis.CONCLUSION Intestinal endometriosis is difficult to diagnose preoperatively because it mimics various intestinal diseases. Thus, if women of reproductive age have ambiguous symptoms and signs with nonspecific radiologic and/or endoscopic findings,intestinal endometriosis should be included in the differential diagnosis.

Endometriosis of the duplex appendix: A case report and review of the literature

BACKGROUND Duplication of the appendix is an infrequent congenital malformation with a complex classification.The horseshoe appendix is a subtype of the duplex appendix and is rarely reported in the literature.Endometriosis is a common gynecological disease that rarely occurs in the appendix.Moreover,horseshoe appendix combined with endometriosis has not been previously reported.CASE SUMMARY Here,we describe a 44-year-old woman who was admitted with a 1-d history of migratory lower right quadrant pain.Physical examination was consistent with the signs of acute appendicitis.The patient underwent an emergency exploratory laparotomy.The distal tip of the appendix was in contact with the cecum by another base,or“horseshoe appendix”.In addition,a small intestinal mass and an ovarian mass were identified.Subsequently,appendectomy,partial resection of the small intestine,and right oophorectomy were successively performed.The histopathology confirmed the diagnosis of acute inflammation of the duplex appendix with endometriosis,small intestine endometriosis,and ovarian endometriosis.CONCLUSION Surgeons need to be aware of the possibility of the duplex appendix when performing an appendectomy,and this study emphasizes the importance of exploring the entire abdomen.

Bowel endometriosis: Colorectal surgeon's perspective in a multidisciplinary surgical team

Endometriosis is a gynecological condition that presents as endometrial-like tissue outside the uterus and induces a chronic inflammatory reaction. Up to 15% of women in their reproductive period are affected by this condition. Deep endometriosis is defined as endometriosis located more than 5 mm beneath the peritoneal surface. This type of endometriosis is mostly found on the uterosacral ligaments, inside the rectovaginal septum or vagina, in the rectosigmoid area, ovarian fossa, pelvic peritoneum, ureters, and bladder, causing a distortion of the pelvic anatomy. The frequency of bowel endometriosis is unknown, but in cases of bowel infiltration, about 90% are localized on the sigmoid colon or the rectum. Colorectal involvement results in alterations of bowel habits such as constipation, diarrhea, tenesmus, dyschezia, and, rarely, rectal bleeding.Differential diagnosis must be made in case of irritable bowel syndrome,solitary rectal ulcer syndrome,and a rectal tumor.A precise diagnosis about the presence,location,and extent of endometriosis is necessary to plan surgical treatment.Multidisciplinary laparoscopic treatment has become the standard of care.Depending on the size of the lesion and site of involvement,fullthickness disc excision or bowel resection needs to be performed by an experienced colorectal surgeon.Longterm outcomes,following bowel resection for severe endometriosis,regarding pain and recurrence rate are good with a pregnancy rate of 50%.

Mucocele of the appendix due to endometriosis:A rare case report

Mucocele of the appendix due to endometriosis is extremely rare,and there are only 10 previously reported cases in the English literature.We report a case of mucocele of the appendix due to endometriosis and provide the first review of the literature.A 43-year-old woman was admitted to the hospital because of recurrent right lower abdominal pain during her menstrual periods.Colonoscopy revealed submucosal tumorlike elevations of the appendiceal orifice.Computed tomography and magnetic resonance imaging of the abdomen suggested cystic lesions near the appendix.Consequently,mucocele of the appendix was suspected preoperatively.An open ileocecal resection was performed.Multiple cystic lesions were observed around the appendix.The cystic lesions contained mucus.Histopathological examination was consistent with a mucocele of the appendix due to endometriosis.The postoperative course was uneventful.We present the first review of the literature to clarify the clinical features.