Visualization of diaphragmatic fenestration associated with catamenial pneumothorax

Dynamics of thoracic endometriosis in the pleural cavity

Background

Thoracic endometriosis-related pneumothorax is a secondary spontaneous pneumothorax caused by thoracic endometriosis. Diaphragmatic endometriosis is well-studied, but visceral and/or parietal pleural lesions are not. Although surgery is an effective treatment, postoperative recurrence rates are unsatisfactory probably due to inadequate understanding of underlying pathophysiology. We aimed to clarify the clinicopathological features of thoracic endometriosis.

Methods

In total, 160 patients who underwent thoracoscopic surgery from a single institution with histopathologically proven thoracic endometriosis from January 2015 to December 2019 were included. Clinicopathological characteristics and surgical outcomes were assessed retrospectively.

Results

The cohort median age was 41 (range 22–53) years. Pneumothorax was right-sided in 159 (99.4%) and left-sided in only 1 (0.6%) case. Visceral and parietal pleural lesions were diagnosed in 79 (49.4%) and 71 (44.4%) patients, respectively. In total, 104 visceral pleural lesions and 101 parietal pleural lesions were detected. The S⁴ region and the dorsal 6^th intercostal space contained the largest number of visceral pleural (66 lesions) and parietal pleural lesions (25 lesions), respectively. Histopathological evaluation revealed endometriotic tissues, existing in the outer external elastic layer in all lesions, were localized or invaded deeply. The median follow-up period was 370 (range, 6–1824) days. The Kaplan-Meier method revealed that the 1- and 2-year postoperative recurrence rates were 13.8% and 19.3%, respectively.

Conclusions

Visceral pleural endometriotic lesions may be disseminated from the visceral pleural surface and infiltrate into the pleura. Intraoperatively, careful observation of the specific sites, such as the visceral pleura of S⁴ and the parietal pleura of 6^th intercostal space, is important to reduce postoperative recurrence.

Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach

The present review aims to analyse the current data available on the feasibility, safety and effectiveness of the minimally invasive surgical (MIS) treatment of diaphragmatic endometriosis (DE). Through the use of PubMed and Google Scholar database, we conducted a literature review of all available research related to diagnosis and treatment of DE, focussed on the minimally invasive techniques. The studies were selected independently by two authors according to the aim of this review. DE is an under-diagnosed disease affecting between 0.1% and 1.5% of fertile women. It is predominantly multiple, asymptomatic and highly associated with pelvic disease in about 50-90%. MIS techniques seems to be safe, effective and feasible in tertiary advanced endometriosis centre, offering definitive advantages in terms of hospital stay, post-operative pain and return to normal activity by using several surgical techniques as hydro-dissection plus resection, laser CO₂ vaporisation, electrical fulguration, Sugarbaker peritonectomy, partial (shaving) and full-thickness diaphragmatic resection. Symptoms control range from 85% to 100%, with less than 3% of conversion, peri-operative complications and recurrence rate. All cases must be performed by multidisciplinary teams including at least a gynaecologist, thoracic surgeon and anaesthetist. The lack of prospective evaluation of DE interferes with the understanding about the natural history of disease and treatment results. Therefore, the development of adequate evidence-based recommendations about diagnosis, management and follow-up is difficult at this moment.

Catamenial Pneumothorax: A Rare Cause of Chest Pain in the Emergency Department

Catamenial pneumothorax (CP) is defined as recurrent spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. The aetiology of this syndrome is unknown, although many theories have been proposed to explain it. A 43-year-old female presented to our emergency room with a complaint of left sided chest pain. She had no dyspnoea or haemoptysis during the admission. She had a history of pelvic endometriosis without any complaints for three years. Pneumothorax or pneumonia was not detected on chest X-ray. Blood tests and electrocardiogram findings did not support any cardiac or infectious cause. Computed tomography showed a pneumothorax on the mediastinal side of left hemithorax. The patient was referred to a thoracic surgeon. A thoracoscopy for histological confirmation was performed and the diagnosis of CP was made with a histological intervention.

Catamenial pneumothorax - a review of the literature

Catamenial pneumothorax should be defined as recurrent accumulation of air in the pleural cavity in reproductive-age women without concomitant respiratory diseases. The sine qua non criterion is the occurrence of the pneumothorax in the period of 72 hours before or after the menses. Additional criteria include characteristic pleural lesions, right-sided occurrence, and coexistence of endometriosis. There are no radiological or pathological conditions allowing an exact confirmation of catamenial pneumothorax. In the case of catamenial pneumothorax, treatment failure most commonly consists in disease recurrence. It may occur even as late as several years after the initial treatment. The recurrence rate in patients undergoing surgery ranges from 8% to 40%. Finding and resecting the visible pleural lesions is of key importance during surgical treatment. Reconstruction of the diaphragm must be performed in every patient in whom diaphragmatic perforations are found. Hormonal therapy seems to be effective in sustaining the effects of surgical treatment.

Hormonal therapy after the operation for catamenial pneumothorax - is it always necessary?

Background

Our recent clinical observations put into question the routine hormonal therapy for pneumothorax recurrence prevention, in patients operated for catamenial pneumothorax (CP).

Methods

Retrospective review of the treatment of four women operated for CP in a recent 32-months period.

Results

The four presented patients with CP represent 4.8 % of the overall number of patients operated for spontaneous pneumothorax and 19 % of women operated for pneumothorax in the same period. In all patients, typical multiple diaphragm holes existed. The involved part of the diaphragm was removed with diaphragm suture in three patients, whilst in one patient, a diaphragm placation was done. Endometriosis was histologically confirmed in two patients. During the follow-up period of 6–43 months, none of the patients underwent a postoperative hormonal therapy for different reasons, and in none of them the pneumothorax recurrence occurred.

Conclusion

The clinical course of these patients, with the absence of the pneumothorax recurrence despite the omission of the hormonal treatment, suggests that the appropriateness of the routine hormonal treatment with gonadotrophin-releasing hormone analogues for 6–12 months, should be reconsidered and re-evaluated in further studies.

Multidisciplinary treatment for thoracic and abdominopelvic endometriosis

BACKGROUND AND OBJECTIVES

Thoracic endometriosis is a rare form of extragenital endometriosis with important clinical ramifications. Up to 80% of women with thoracic endometriosis have concomitant abdominopelvic endometriosis, yet the surgical treatment is usually performed with separate procedures. This is the largest published series of the combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic and thoracic endometriosis. The objectives of this series are to further evaluate the manifestations of thoracic endometriosis, assess the multidisciplinary surgical approach, and discuss our institution's protocols.

METHODS

This is a retrospective, institutional review board-approved case series of 25 consecutive women who underwent combined video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic, diaphragmatic, and thoracic endometriosis from January 1, 2008, to September 30, 2013. All surgeries were performed at a tertiary referral center by the same primary surgeons. Data were collected by chart review.

RESULTS

Twenty-five patients were included, with a mean age of 37.7 years. Eighty percent of patients had catamenial chest pain, and in 40% this was their only chest complaint. Shoulder pain was noted in 40% of patients, catamenial pneumothorax in 24%, and hemoptysis in 12%. One hundred percent of patients were found to have endometriosis in the pelvis, 100% in the diaphragm, 64% in the chest wall, and 40% in the parenchyma. There were 2 major postoperative complications: 1 diaphragmatic hernia and 1 vaginal cuff hematoma.

CONCLUSION

Clinical suspicion and preoperative assessment are crucial in the diagnosis of thoracic endometriosis and allow for a multidisciplinary approach. The combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of endometriosis optimally addresses the pelvis, diaphragm, and thoracic cavity in a single operation.

A case of young woman with recurrent right pleural effusion

Endomterisois is usually found in women of child-bearing age. A case is presented of massive right-sided pleural effusion caused by endometriosis. The final diagnosis was made by thoracoscopic pleural biopsy. Physicians should be aware of this potentially treatable cause of pleural effusion having excluded other possibilities such as malignancy and tuberculosis.

Catamenial pneumothorax

Catamenial pneumothorax (CP) is the most common form of thoracic endometriosis syndrome, which also includes catamenial hemothorax, catamenial hemoptysis, catamenial hemopneumothorax and endometriosis lung nodules, as well as some exceptional presentations. Usually onset of lung collapse is less than 72 hours after menstruation. Most commonly occurs in women aged 30-40 years, but has been diagnosed in young girls as early as 10 years of age and post menopausal women (exclusively in women of menstrual age) most with a history of pelvic endometriosis. Diagnosis can be hinted by high recurrence rates of lung collapse in a woman of reproductive age with endometriosis. Moreover; CA-125 is elevated. Video-assisted thoracoscopy or medical thoracoscopy is used for confirmation. In our current work we will present all aspects of CP from diagnosis to treatment.

Anesthetic evaluation and management of a patient with thoracic endometriosis syndrome presenting for elective surgery

Thoracic endometriosis syndrome is a relatively uncommon disorder characterized by recurrent pneumothoraces, hemothorax, chest pain, dyspnea, and hemoptysis within 48 to 72 hours of menstruation. A 34 year old, ASA physical status 2 woman with recurrent catamenial pneumothoraces due to thoracic endometriosis syndrome is presented. After treatment with video-assisted thoracoscopic surgery, she underwent successful elective diagnostic abdominal laparoscopy without incident. The presence of parenchymal injury and damage predisposes these patients to ventilator-induced lung injury. Postponement of surgery until the intermenstrual period, with lung protective ventilation, allows patients with this disease to successfully undergo general anesthesia and surgery.

Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature

OBJECTIVE

Spontaneous recurrent pneumothorax during menstruation is reported as catamenial pneumothorax. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women. The percentage among women referred for surgery is significantly higher (25-30%). Although it usually involves the right-side (85-95%) it can be left-sided or bilateral. It is associated with diaphragmatic perforations and/or thoracic endometriosis. There is pelvic endometriosis in up to 30-51% of cases. The lesions that are not always found may present as small or larger holes at the central tendon of the diaphragm, as red, blueberry, brown spots or larger nodules at the diaphragm, the visceral or parietal pleura. Lesion histology may reveal endometriosis. We present 5 cases of catamenial pneumothorax treated surgically during the last 6 years.

PATIENTS AND METHODS

Five women, with a mean age of 34+/-9.9 years (median 38, range, 19-45 years) presented with right-sided recurrent catamenial pneumothorax. In 3 patients diaphragmatic perforation(s) were found; perforation suturing (n=1), and diaphragmatic plication reinforced with bovine pericardial patch (n=1) were performed. All patients underwent atypical resection of upper and/or middle lobe segments of lung parenchyma that appeared abnormal (haemorrhagic/emphysematous or blebs). Four patients underwent pleurodesis and 1 patient underwent pleurectomy. Four interventions were performed through video assisted thoracoscopic surgery, while diaphragmatic plication was performed through a video assisted mini-thoracotomy. Histology did not reveal endometriosis tissue.

RESULTS

The postoperative course was uneventful. The patients were extubated in theatre and were discharged home at a mean of 7+/-4 days (median 6 days, range, 4-14 days). Two of them received hormonal therapy [Gonadotropin Releasing Hormone (GnRH) analogue] postoperatively. At a follow-up of 14.16 patient-years (mean 2.83+/-1.08 years, range, 1.33-3.83 years) there was recurrence, 6.5 months postoperatively, in one patient that had not undergone closure of a tiny diaphragmatic hole and had not received hormonal treatment postoperatively. She was treated medically (amenorrhea for 6 months with GnRH analogue) and had no further recurrences (in 3.3 years).

CONCLUSIONS

Surgery is the treatment of choice of catamenial pneumothorax. It should aim to complete management of all lesions. The most common complication is recurrence. Early diagnosis and multidisciplinary treatment including hormonal therapy may be beneficial in high risk patients.

Bilateral thoracic endometriosis affecting the lung and diaphragm

INTRODUCTION

Endometriosis of the lung and the diaphragm is rare. Patients may present with symptoms such as shortness of breath, chest pain, and shoulder pain or they may be asymptomatic. Of note, there have been few reports of bilateral catamenial disease, and no reports, to our knowledge, of bilateral pathology proven pulmonary parenchymal endometriosis.

CASE

A 43-year-old with stage IV endometriosis and large leiomyoma underwent a laparoscopic hysterectomy and treatment of endometrial lesions in 2005. In March and April of 2011, she presented with bilateral pneumothoraces. She subsequently underwent video-assisted thoracoscopy as well as resection and fulguration of bilateral lung and diaphragmatic endometriosis. Pathology confirmed endometrial implants in the lung parenchyma bilaterally.

CONCLUSION

Catamenial pneumothorax is the most common presentation of thoracic endometriosis. However, bilateral catamenial pneumothoraces are rare. To the best of our knowledge, this case reflects the first report of pathology proven bilateral lung and diaphragm endometriosis.

Diaphragmatic Fenestrations in Catamenial Pneumothorax: A Management Strategy

Video-assisted thoracoscopic exploration of the right hemithorax in a 37-year-old woman with recurrent catamenial pneumothorax revealed multiple diaphragmatic fenestrations. She underwent successful plication of the diaphragm, with no recurrence of pneumothorax after 4 years of follow-up.

Bilateral pleural endometriosis

The patient was a 40-year-old woman with a 1-year history of catamenial chest pain and a recent bilateral hemothorax. She underwent a left thoracotomy for surgical pleurodesis, and a pleural biopsy. Subsequently, she had a hysterectomy in conjunction with an oophorectomy. The pathologic investigation of the pleura revealed an endometrial implant. The postoperative course was uneventful with no recurrence of hemothorax and chest pain during the first 6 months and at the patient's follow-up. This is a very rare case of a patient with thoracic endometriosis presenting with bilateral hemothorax.

Thoracic Endometriosis: Current Knowledge

Thoracic endometriosis syndrome includes four well-recognized clinical entities, namely catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis and lung nodules, as well as some exceptional presentations. The etiological mechanisms of this syndrome are not well understood, and different theories have been proposed. Controversies exist about optimal management, as experience has been drawn from case reports and small clinical series. Surgery, hormonal treatments and combined approaches have all been proposed, with variable results in terms of short and long term outcome.

Catamenial pneumothorax

Catamenial pneumothorax is defined as spontaneous pneumothorax occurring within 72 hours before or after onset of menstruation. Although catamenial pneumothorax is the most common clinical manifestation of intrathoracic endometriosis, this latter condition is not universally identified in women with catamenial pneumothorax and cannot fully explain the recurrent and cyclical episodes of pneumothorax. Therefore, the etiology of this syndrome is unknown, although many theories have been proposed to explain it. We describe a 37-year-old woman with recurrent episodes of spontaneous right-sided pneumothorax and chest pain that occurred close to her menstrual periods. The patient's condition did not abate after initial surgical exploration with abrasive mechanical pleurodesis or after hormonal suppressive therapy at an institution elsewhere. The patient was referred to our institution for further evaluation. A second surgical inspection of the pleural cavity and diaphragm disclosed the presence of multiple diaphragmatic fenestrations that were closed surgically at that time. Postoperatively, the patient discontinued hormonal suppressive therapy, and menstrual cycles became regular. Six months after surgery, the patient remains asymptomatic with no evidence of recurrence of pneumothorax. This case supports recent reports that diaphragmatic defects are often present in patients with catamenial pneumothorax. Surgical exploration to inspect the diaphragm and to close all Identified defects should be performed in patients who continue to experience pneumothorax despite effective hormonal suppression.

Catamenial pneumothorax revisited: Clinical approach and systematic review of the literature

BACKGROUND

Catamenial pneumothorax is a rare entity of spontaneous, recurring pneumothorax in women. It has been associated with thoracic endometriosis, yet varying clinical courses and the lack of consistent intraoperative findings have led to conflicting etiologic theories.

METHODS

We discuss etiology, clinical course, and surgical treatment of 3 women with catamenial pneumothorax. In addition, the world literature since the first description is reviewed.

RESULTS

Three women (31, 32, and 39 years old) had recurrent, menses-associated, right-sided spontaneous pneumothoraces. They had undergone video-assisted thoracoscopic surgery previously, with various unsuccessful procedures. Finally, with video-assisted thoracoscopic surgery multiple small perforations in the tendinous part of the right diaphragm with adjacent endometrial implants were detected. After plication of the involved area, 2 patients have been free of recurrence for 22 and 13 months, respectively. Laparoscopic evaluation in 1 woman with a further recurrence revealed asymptomatic pelvic endometriosis. This patient has been free of recurrence since initiation of luteinizing hormone-releasing hormone analog therapy for 17 months. In a review of 229 cases of catamenial pneumothorax in the literature, adequate information was given for 195 patients (85.2%). One hundred fifty-four (79%) were treated surgically, with detailed findings reported for 140 (91%). Thoracic endometriosis was diagnosed in 73 patients (52.1%), and 54 (38.8%) showed diaphragmatic lesions. Pleurodesis, with or without diaphragmatic repair or wedge resection, was performed in 81.7% of the cases.

CONCLUSIONS

Catamenial pneumothorax may be suspected in ovulating women with spontaneous pneumothorax, even in the absence of symptoms associated with pelvic endometriosis. During video-assisted thoracoscopic surgery, inspection of the diaphragmatic surface is paramount. Plication of the involved area alone can be successful. In complicated cases, hormonal suppression therapy is a helpful adjunct.

Catamenial pneumothorax: a prospective study

OBJECTIVES

To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms.

DESIGN

A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded.

SETTING

A university hospital.

METHODS

At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used.

RESULTS

In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found.

CONCLUSIONS

Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

Catamenial pneumothorax caused by endometriosis in the visceral pleura

Catamenial pneumothorax is a rare clinical entity of unknown etiology. The most well known hypothesis is passage of air from the genital tract through endometrial fenestrations in the diaphragm. Although some reports are associated with diaphragmatic endometriosis, few have been confirmed endometrial implants in the visceral pleura. We describe a very rare case of catamenial pneumothorax caused by ectopic endometriosis in the visceral pleura confirmed histopathologically in a woman 1-year after hysterectomy.

Spontaneous pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect

Despite its obvious benefits, laparoscopic surgery is not free of complications. It may cause significant physiologic changes and technical mishaps. Pneumothorax has been described as a complication of almost any type of laparoscopic surgery. We report a case of tension pneumothorax during laparoscopic adrenalectomy secondary to a congenital diaphragmatic defect and describe our treatment.

Anesthetic implications of thoracic endometriosis

Endometriosis occurs in 5% to 10% of women of childbearing age and involves the proliferation of endometrial tissue outside the uterine cavity. Thoracic endometriosis is the most frequent extrapelvic manifestation of endometriosis, numbering some 100 reported cases. It may include spontaneous pneumothorax, hemoptysis, chest pain, bronchiectasis, pneumomediastinum, or mediastinal bleeding. Because the tissue is hormonally responsive, all of these manifestations are related to the menstrual cycle (catamenial) and are likeliest to occur during menses. We report the successful anesthetic management of a patient with thoracic endometriosis and recurring catamenial pneumothorax who presented for elective pelvic surgery.