Post-salpingectomy endometriosis: An under-recognized entity

Abstract

We report a case of a 48-year old lady, who presented with complaints of lower abdominal pain and menorrhagia for the last four months. The patient had undergone bilateral salpingectomy four years back by the Pomeroy technique. Ultrasonography revealed an ovarian cyst on the right side. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed and the specimen was sent for histopathological examination. It revealed that the normal mucosa of the tubectomy stump was completely replaced by endometrial tissue. Tubal endometriosis remains an under-recognized entity, due to less extensive routine sampling of the fallopian tubes, and they may be also be associated with other pathologies, as was in the present case.

Tubal origin of ovarian endometriosis

“…Endometrialization of the fallopian tube representing endometrium-like tissue within the proximal end of the tubal segment is commonly observed in patients who underwent tubal ligation for undesired fertility. [33][34][35] Although we cannot exclude the possibility of endometrial colonization for those tubal ligation cases, many investigators believe that metaplasia from tubal epithelia seems more likely as a transitional area from normal looking tubal epithelia to minimally formed endometriosis or endometriallike tissue are commonly present. 27,36 In order to Oviduct contributing to ovarian endometriosis form ovarian endometriosis, tubal cells have to find a reasonable route to get onto the ovary.…”

Post salpingectomy intraluminal endometriosis in a premenopausal lady - an incidental finding often paid less attention to

“…The standard textbooks and the literature referenced here all mention three types of tubal endometriosis-firstserosal (most common type encountered), Second-the normal morphologic variation also termed as endometrial colonisation, which is seen in isthmic and interstitial part of fallopian tube and Third-post salpingectomy endometriosis. 6 The latter two are under recognised types possibly due to 1) lack of knowledge and awareness among pathologists about them 2) The fact that they don't present as specific gynaecological diseases 3) sampling of fallopian tube in hysterectomies is more of a completion procedure and not a part of specific diagnosis as otherwise would be done when salpingectomy is specifically clinically indicated for conditions like hematosalphinx, torsion etc. in the pre-menopausal age group.…”

Endometriosis and the Fallopian Tubes: Theories of Origin and Clinical Implications

“…Secondly, endometriotic implants can invade the tubal mucosa, which is known as “endometrial colonisation” and is considered to have a distinct pathogenesis [ 24 ]. This can be part of a normal morphological variation; endometrial mucosa has been reported to replace the mucosa of the tubal interstitium in 25% and tubal isthmus in 10% of women [ 25 ]. However, ectopic endometrial tissue can grow into the tubal lumen and cause obstruction, which is known as “intraluminal endometriosis”.…”

“…This form of tubal endometriosis has been found in 20–50% of tubes examined after ligation, and typically occurs 1 to 4 years following the procedure [ 26 ]. An increased incidence is associated with long post tubal ligation intervals, short proximal stumps and the use of electrocautery for ligation [ 25 ]. These three forms of tubal endometriosis have distinctly different pathologies and consequently affect different patient groups and may give rise to different symptoms.…”