An advanced flexible laparoscope with wide optic angle for observing diaphragmatic lesions associated with catamenial pneumothorax

Thoracic Endometriosis: A Review Comparing 480 Patients Based on Catamenial and Noncatamenial Symptoms

OBJECTIVE

This review aimed to categorize thoracic endometriosis syndrome (TES) according to whether the presenting symptoms were catamenial and to evaluate whether such a categorization enables a better management strategy.

DATA SOURCES

An electronic search was conducted using the PubMed/Medline database.

METHODS OF STUDY SELECTION

The following keywords were used in combination with the Boolean operators AND OR: "thoracic endometriosis syndrome," "thoracic endometriosis," "diaphragm endometriosis," and "catamenial pneumothorax."

TABULATION, INTEGRATION, AND RESULTS

The initial search yielded 445 articles. Articles in non-English languages, those whose full texts were unavailable, and those that did not present the symptomatology clearly were further excluded. After these exclusions, the review included 240 articles and 480 patients: 61 patients in the noncatamenial group and 419 patients in the catamenial group. The groups differed significantly in presenting symptoms, surgical treatment techniques, and observed localization of endometriotic loci (p <.05).

CONCLUSION

This review points out the significant differences between patients with TES with catamenial and noncatamenial symptoms. Such categorization and awareness by clinicians of these differences among patients with TES can be helpful in designing a management strategy. When constructing management guidelines, these differences between patients with catamenial and noncatamenial symptoms should be taken into consideration.

The Importance of Stromal Endometriosis in Thoracic Endometriosis

Thoracic endometriosis (TE) is a rare type of endometriosis, where endometrial tissue is found in or around the lungs and is frequent among extra-pelvic endometriosis patients. Catamenial pneumothorax (CP) is the most common form of TE and is characterized by recurrent lung collapses around menstruation. In addition to histology, immunohistochemical evaluation of endometrial implants is used more frequently. In this review, we compared immunohistochemical (CPE) with histological (CPH) characterizations of TE/CP and reevaluated arguments in favor of the implantation theory of Sampson. A summary since the first immunohistochemical description in 1998 until 2019 is provided. The emphasis was on classification of endometrial implants into glands, stroma, and both together. The most remarkable finding is the very high percentage of stromal endometriosis of 52.7% (CPE) compared to 10.2% (CPH). Chest pain, dyspnea, right-sided preference, and diaphragmatic endometrial implants showed the highest percentages in both groups. No significant association was found between the recurrence rate and the various appearances of endometriosis. Sometimes in CPE (6.8%) and CPH (30.6%) no endometrial implants were identified underlining the importance of sensitive detection of endometriosis during and after surgery. We suggest that immunohistochemical evaluation should become mandatory and will improve diagnosis and classification of the disease.

Endometriosis of Diaphragm: A Case Report

Endometriosis affects about 10% of women of reproductive age. Its main feature is the presence of stroma and endometrial glands in sites other than the uterus, mainly in pelvis. Pelvic peritoneum, ovaries, uterine ligaments, bladder, intestines, andcul-de-sac are among the affected areas. Sometimes endometriosis can be found outside of the pelvis and even above abdominal cavity, like indiaphragm.Herein, we present a case of an asymptomatic diaphragmatic endometriosis that was discovered incidentally during laparoscopy of pelvic endometriosis, as well as our appropriately proposed treatment protocol.

Four Cases of Postoperative Pneumothorax Among 2814 Consecutive Laparoscopic Gynecologic Surgeries: A Possible Correlation Between Postoperative Pneumothorax and Endometriosis

STUDY OBJECTIVES

To evaluate the frequency of pneumothorax after laparoscopic surgery and to identify possible correlations to endometriosis.

DESIGN

Retrospective review.

SETTING

Tokyo University Hospital between 2006 and 2013.

PATIENTS

Four patients among a total of 2814 patients with a postoperative pneumothorax.

INTERVENTION

Laparoscopic surgery for gynecologic benign disease. The main outcome was the clinical frequency and characteristics of the patients with postoperative pneumothorax.

MEASUREMENTS AND MAIN RESULTS

We observed 4 (0.14%) cases of postoperative pneumothorax after laparoscopic surgery, all of whom were diagnosed with endometriomas and developed a right-sided pneumothorax. The incidence of postoperative pneumothorax in 1097 patients with endometriomas was 0.36%, which was significantly higher than those without endometriomas.

CONCLUSION

The presence of endometrioma should be considered a risk factor for postoperative pneumothorax in gynecologic laparoscopic surgery.

Gynecologic evaluation of catamenial pneumothorax associated with endometriosis

STUDY OBJECTIVE

To assess the pathogenesis of catamenial pneumothorax associated with endometriosis from a gynecologic perspective.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Eleven patients with clinically suspected catamenial pneumothorax due to frequently recurrent pneumothorax who underwent thoracoscopy between September 2003 and February 2007 at our hospital.

INTERVENTION

Video-assisted thoracoscopy.

MEASUREMENTS AND MAIN RESULTS

Episodes of pneumothorax, coexistence of intrapelvic endometriosis, classification of intrathoracic lesions according to the appearance of pelvic endometriosis using the revised American Society of Reproductive Medicine (re-ASRM) classification, and histopathologic findings in intrathoracic specimens were assessed. A total of 38 episodes of pneumothorax, all on the right side, were documented in 11 patients with catamenial pneumothorax. Median (range) patient age at the initial pneumothorax was 42 (29-47) years. The re-ASRM score in 6 patients in whom pelvic endometriosis was directly observed at laparoscopy and laparotomy was 56 (18-96). We postoperatively reviewed videotape recordings of video-assisted thoracoscopy, and observed superficial thoracic diaphragmatic lesions classified as red (n = 5), black (n = 8), and white (n = 9) with fenestration according to the re-ASRM classifications for pelvic endometriosis. Tissue associated with endometriosis was detected at histopathologic analysis of resected diaphragmatic lesions in 9 patients. No endometriosis was identified at histopathologic analysis of visceral pleural lesions in 7 patients who underwent lung resection.

CONCLUSIONS

Gynecologic evaluation of catamenial pneumothorax associated with endometriosis is crucial to clarify the unelucidated pathogenesis of the disease.

Endometriosis of the diaphragm: four cases treated with a combination of laparoscopy and thoracoscopy

STUDY OBJECTIVE

We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution.

DESIGN

Case series (Canadian Task Force Classification II2).

SETTING

Tertiary care referral center.

PATIENTS

Four women with diaphragmatic endometriosis.

INTERVENTIONS

Laparoscopy and thoracoscopy.

MEASUREMENTS

We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008.

MAIN RESULTS

Four patients underwent a combination of laparoscopy for treatment of abdominopelvic endometriosis and thoracoscopy for treatment of diaphragmatic endometriosis. All patients had a history of chest pain. Three had a history of pelvic pain. Two had a history of catamenial hemothorax or pneumothorax. Two had been previously diagnosed with endometriosis, and three had a history of hormonal pharmacotherapy. All underwent laparoscopy and thoracoscopy without complications. All had uneventful recoveries. At nine-month follow-up, all patients were free of chest pain, and one patient had recurring pelvic pain.

CONCLUSIONS

To the best of our knowledge, this constitutes the only reported series of patients with endometriosis who underwent a procedure systematically combining both laparoscopy and thoracoscopy for treatment of abdominopelvic and thoracic disease. It confirms that combined laparoscopic and thoracoscopic diagnosis and management of diaphragmatic endometriosis is reasonable. The inferior aspect of the diaphragm should be evaluated in all patients undergoing laparoscopy for endometriosis. Concomitant thoracoscopy should be considered for all patients with history of catamenial hemopneumothorax, cyclic chest or shoulder pain, or cyclic dyspnea. The aim of treatment should be to remove endometriotic lesions, to provide symptomatic relief, and to avoid recurrence. The use of these minimally invasive techniques may reduce the need for laparotomy or thoracotomy in affected patients.

Evaluation of a prototype flexible digital video hysteroscope (Y0001)

A prototype flexible DV hysteroscope (Y0001) with a tip diameter of 4.8 mm was investigated through comparisons with two other hysteroscopes with subequal tip diameters: A rigid office hysteroscope (OHS) and a hystero-fiberscope (1T). The angle of view, area of coverage, and resolution were compared for each hysteroscope. The angles of view of Y0001 and 1T were found to be significantly larger than that of OHS (p<0.005 and p<0.02, respectively). Y0001 and 1T also had significantly larger areas of coverage than OHS (p<0.005 and p<0.05, respectively). At a focal distance of 5 mm, there was no significant difference in resolution between Y0001 and OHS (p>0.1). The resolution of OHS was marginally higher than that of 1T at this distance, although the difference was not significant (0.05<p<0.1). OHS and Y0001 were also compared in terms of their ease of use in a case of submucosal myomectomy; the viability of the intraoperative images obtained from the two devices was also compared. Y0001 was shown to be superior to OHS in its capability to flexibly reach the recesses of the uterine cavity. The success rate of hysteroscopic biopsy with Y0001 was 100%. The study shows that Y0001 has a wider angle of view, larger area of coverage, and better usability than OHS, indicating that flexible surgical hysteroscopes may be less liable to cause intraoperative complications than rigid hysteroscopes.