Do you know about parietal endometriosis and its dedicated treatment, percutaneous cryotherapy?

There is no one form of endometriosis, but there are several types. In fact, this disease, which consists of the presence outside the uterus of tissue fragments similar to the endometrium, is distinguished by three forms, often associated with each other: superficial (peritoneal) endometriosis, ovarian endometrioma and deep pelvic endometriosis (sub -peritoneal). However, even if it is a disease that is increasingly discussed, the knowledge of the French remains fragile, as revealed by a survey by the agency Finn Partners carried out with OpinionWay. The latter indicates that 51% of the French say they lack information about endometriosis and, above all, that 57% do not know that there are many types today. Added to this is the fact that, although endometriosis mainly affects the endopelvic cavity, namely the internal genital organs, the uterosacral ligaments and the bladder, this condition can affect the whole body of the woman, the High Health Authority (HAS) estimates that extra. -the genital areas represent, according to some studies, at least 5% of injuries.

Lesions can particularly be found on abdominal wall scars, including cesarean section, episiotomy, and hysterectomy scars. This condition has a specific name: parietal endometriosis. Clinically rarer, the latter is the most common form of extra-pelvic involvement, affecting the abdominal wall. Less described in scientific communication, it is therefore less known by the general public or even by the doctors themselves and therefore “ often under diagnosed » according to Dr. Emilie Faller, gynecological surgeon at the EndoAlsace expert center, at the CHRU* in Strasbourg. “It is known that endometriosis can affect the pelvic cavity, but when it comes to the muscles of the abdominal wall, many people do not know that it can be.” As a general rule, this type of endometriosis occurs 2 and a half years after a surgical procedure: more often a caesarean section (HAS suggests an incidence of 0.3 to 1%) or more rarely a laparoscopy (surgical technique that allows to approach the inside of the abdomen and pelvis without opening the stomach).

“Pain is very often cyclical because it is linked to periods”

In the absence of any other physiopathological explanation to date, the Strasbourg CHRU points out that the most logical assumption is that the dissemination of endometrial cells is directly related to the surgical process, which implants it outside the uterus during intervention. In other words, after a caesarean section, the endometrial cells migrate towards the intestinal wall and in particular at the level of the scar and that they then lead to the formation of nodules (abnormal formation, usually rounded and small in an organ or on its surface ). ” In the case of laparoscopy, for example, we open the stomach to place a small camera at the level of the navel with small tweezers and we operate via a screen and it is possible that the endometrial cells are grafted at this level in the abdominal wall, which cause nodules to the scars. But sometimes they are millimeter cells. », adds Dr. Emilie Faller. The specialist points out that “ It is in each period that these cells will bleed before they “stick” and form nodules that will grow little by little. »

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Due to this particularity, the symptom mainly felt by the patients concerned will be, according to the EndoFrance association, the pain in the area of ​​the scars (in some cases the small nodules can be felt on palpation) and the bleeding in the navel area (laparoscopy scar), also knowing that ” In some cases, endometriosis cells can migrate beyond the scars and cause abdominal pain. » « The pain is very often cyclical because it is linked to periods, like most endometriosis. Patients may also feel a small nodule that hurts during this period because it has to be cultivated before returning to normal later. But it will return every month to the point that this lump becomes large enough to cause constant pain. », says Dr. Emilie Faller. Note that although parietal endometriosis can be associated with pelvic endometriosis, the occurrence is rare: from 5 to 15% of cases according to EndoFrance. This is why patients can be faced with a delay in diagnosis, already estimated at 7 years in general.

Moral endometriosis: from diagnosis to treatment

Indeed, the gynecologist believes that “ the link to be established between pain in the abdomen and periods may take longer for patients. Especially because they do not necessarily have the exact symptoms of pelvic endometriosis: pain when having a bowel movement, during intercourse, etc. That is why, in the absence of these more “typical” symptoms, the diagnosis can be made. be after » Most of the time, when it is not very deep, and in the absence of excessive abdominal fat, patients consult because they themselves have felt a painful nodule that worries them. However, it turns out that “ if it is a few small millimeter cells, we will always have to wait a certain time before it should be really symptomatic and felt since the nodule grows with the period. What is the most appropriate exam? The Strasbourg University Hospital recommends MRI, for the simplicity that provides an advantage over ultrasound, that of being more specific for the internal analysis of the lesion and therefore allows a differential diagnosis with another muscle mass.

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Once the diagnosis has been made, the management of parietal endometriosis is done through consultation between the gynecological surgeon, the interventional radiologist and the patient. And, above all, according to the symptoms, remembers Emilie Faller: “ It is case by case, for example, if the endometriosis does not bother the patient and the latter can live with it without consequences, it is not necessary to treat. The same goes for a patient who also has pelvic endometriosis and who is already taking the pill to block the onset of periods and the associated pain and who is not, therefore, presented with a painful nodule. On the other hand, in the case of a patient who does not have pelvic pain, but a nodule at the level of a scar and does not want to take the pill, it is possible to offer her surgical treatment. VSar if the standard therapy, as first intention, is based on continuous hormonal treatment with the aim of avoiding the cyclic hypertrophy of the nodules and the associated pain suppressing menstrual cycles, some patients, observe the gynecologists, refuse more than taking hormones.

Removal of nodules with cold: a pioneering technique to help patients

When this first treatment is insufficient, until recently, there was only one option: to remove the painful nodules through surgery. An operation considered invasive since it requires the opening of the abdomen to be able to reach the aponeurosis, under which the nodules are nested. But its excision sometimes extends further, damaging the muscle, which leads to a significant risk of after effects and post-operative complications. This type of surgery is therefore likea solution of disproportionate proportions to treat parietal endometriosis. ” To surgically remove the nodules, you need to open the skin, open the muscle, find it and recreate a scar, which was often painful. But now we have the possibility to send patients to consult a radiologist, who take advantage of very precise imaging methods to locate the nodule, this is a real progress. “, the gynecologist attests. In any case, the fact of using thermal treatment (hot or cold) rather than the scalpel to remove a mass of invasive tissue is one of the specialties of interventional radiology.