Laparoscopic surgical management of diaphragmatic endometriosis

Robotic-Assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients

STUDY OBJECTIVE

To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE).

DESIGN

Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database.

SETTING

Tertiary referral center. Endometriosis care center.

PATIENTS

Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023.

INTERVENTIONS

Robotic excision of severe DE.

MEASUREMENT AND MAIN RESULTS

Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery.

CONCLUSION

In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

Tailoring radicality in diaphragmatic surgery for deep endometriosis: A matter of choice

Diaphragmatic endometriosis (DpE) is a rare disease localization which represents an important clinical challenge. The main criticisms toward the proper DpE management consist of poor consensus on both surgical indications and the choice between different surgical techniques available to treat the disease. Furthermore, only weak recommendations are provided by current guidelines and surgical management is mostly based on surgeon's experience. As consequence, the lack of standardization about the surgical treatment led to the risk of under- or over-treatments in patients suffering from this form of endometriosis. The latest evidence-based data suggest to adopt a lesion-oriented surgical approach serving as a guide in daily surgical activities, in order to ensure a tailored radicality and reduce the rate of surgery-related complications. Diaphragmatic endometriosis surgery should be performed only by expert surgeons with an extensive oncogynecologic expertise since it represents a technically demanding procedure. A multidisciplinary approach is also mandatory in order to adequately select and treat these patients by minimizing the risk of additional morbidity.

Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases

OBJECTIVE

The aim of this study was to investigate and present the clinical characteristics of diaphragm endometriosis, to approach the pathogenetic mechanisms, and to answer the question of whether this disease can be considered an extended form of pelvic endometriosis.

STUDY DESIGN

It was a retrospective comparative one-to-one analysis of 202 cases. Two groups of patients were compared: Group 1 patients with diaphragm endometriosis vs Group 2 (control group) with pelvis endometriosis, each with 101 patients.

RESULTS

Patients with diaphragm endometriosis had extreme significantly higher prevalence of severe pelvis endometriosis included deep infiltrated endometriosis and severe adhesions in term of complete Douglas obliteration (p value = 0.0001). There was neither age nor BMI difference in two groups. Besides of cyclic shoulder or upper abdomen pain there was no difference of symptoms.

CONCLUSION

Diaphragm endometriosis is a rare condition with an approximate prevalence of 1.1% of all endometriosis cases. Since the symptoms are very specific and patients do not associate the pain with diaphragmatic endometriosis, the symptoms should be asked about explicitly. If patients with diaphragmatic endometriosis have no symptoms, the lesions do not necessarily need to be removed. The pathogenesis is still unclear. The authors of this study consider this disease to be an extended form of severe pelvic and deep infiltrated endometriosis. However, the right-side dominance still cannot be explained. Further research is needed to fully understand the origin of diaphragmatic endometriosis.

Diaphragmatic Endometriosis-A Single-Center Retrospective Analysis of the Patients' Demographics, Symptomatology, and Long-Term Treatment Outcomes

Diaphragmatic endometriosis is rare and forms 0.67-4.7% of all endometriosis cases. Evidence regarding its optimal management is lacking. In this study, we retrospectively analyzed the patient characteristics and long-term treatment outcomes of diaphragmatic endometriosis patients. Over a 4-year period, 23 patients were diagnosed with diaphragmatic endometriosis. The majority of patients had coexisting deep pelvic endometriosis. Cyclic upper abdominal pain was reported by 60.9% of patients, while cyclic chest and shoulder pain were reported by 43.5% and 34.8% of patients, respectively. Most patients were treated with laparoscopic lesion ablation, while 21.1% were treated with minimally invasive excision. The mean follow-up time was 23.7 months. Long-lasting resolution of the chest, abdominal, and shoulder pain occurred in 50%, 35.7%, and 25% of patients, respectively. Nonetheless, 78.9% of patients reported major improvement in their symptoms postoperatively. Significantly higher rates of postoperative shoulder, abdominal, and chest pain were observed in patients who received postoperative hormonal therapy compared with those who did not. All patients treated expectantly remained stable. Therefore, we recommend treating diaphragmatic endometriosis only in symptomatic patients. The risk of incomplete surgery should be minimized by a multidisciplinary diagnostic and therapeutic approach with a careful assessment of the diaphragm and the thoracic cavity.

True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation

STUDY OBJECTIVE

To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE).

DESIGN

Comparison of characteristics of patients with diaphragmatic endometriosis (DE) with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study.

SETTING

Tertiary referral center; endometriosis center.

PATIENTS

A total of 1372 patients with histologically proven endometriosis.

INTERVENTIONS

Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the χ2 test and the Mann-Whitney t test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65 of 1372). There was no significant difference between the 2 groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often preoperatively (27.7% vs 1.8%, p <.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (revised American Fertility Society III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p <.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p <.05).

CONCLUSION

Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.

Phrenic nerve paralysis after bipolar electrocoagulation of endometriosis of the diaphragm: case report and mini review

Objective

To present a case of persistent postoperative elevation of the right hemidiaphragm after bipolar electrocoagulation of diaphragmatic endometriosis, highly likely because of collateral thermal damage to key branches of the phrenic nerve, and review the literature on diaphragmatic endometriosis, focusing on operative treatment.

Design

Case report and mini review.

Setting

Single university-based interdisciplinary endometriosis center.

Patient(s)

A 33-year-old nulliparous patient, initially presenting with right-sided shoulder and back pain accompanied by severe dysmenorrhea and diarrhea. Written consent for the use of anonymized data and images for research purposes was obtained.

Intervention(s)

Laparoscopic surgery with bipolar electrocoagulation of multiple superficial endometriotic lesions on the right hemidiaphragm and excision of bilateral deep infiltrating endometriosis on the sacrouterine ligaments.

Main Outcome Measure(s)

Outcome and complication of surgical treatment of diaphragmatic endometriosis.

Result(s)

Three weeks after surgical treatment, the patient complained of exertional dyspnea and pain in the right flank. Imaging showed a postoperative elevation of the right hemidiaphragm, which did not resolve over the following 6 months. We suspect collateral thermal damage to key branches of the phrenic nerve after bipolar electrocoagulation of extensive superficial diaphragmatic lesions.

Conclusion(s)

During laparoscopic treatment of diaphragmatic endometriosis, bipolar electrocoagulation should be used sparingly and with caution to avoid potentially damaging the phrenic nerve.

Umbilical Endometriosis: A Systematic Literature Review and Pathogenic Theory Proposal

Umbilical endometriosis represents 30–40% of abdominal wall endometriosis and around 0.5–1.0% of all cases of endometriosis. The aim of this systematic review is to revisit the epidemiology, signs, and symptoms and to formulate a pathogenic theory based on literature data. We performed a systematic literature review using the PubMed and Embase databases from 1 January 1950 to 7 February 2021, according to the PRISMA guidelines. The review was registered at PROSPERO (CRD42021239670). Studies were selected if they reported original data on umbilical endometriosis nodule defined at histopathological examination and described as the presence of endometrial glands and/or stromal cells in the connective tissue. A total of 11 studies (10 retrospective and one prospective), and 14 case series were included in the present review. Overall, 232 umbilical endometriosis cases were reported, with the number per study ranging from 1 to 96. Umbilical endometriosis was observed in 76 (20.9%; 95% CI 17.1–25.4) of the women included in studies reporting information on the total number of cases of abdominal wall endometriosis. Umbilical endometriosis was considered a primary form in 68.4% (158/231, 95% CI 62.1–74.1) of cases. A history of endometriosis and previous abdominal surgery were reported in 37.9% (25/66, 95% CI 27.2–49.9) and 31.0% (72/232, 95% CI 25.4–37.3) of cases, respectively. Pain was described in 83% of the women (137/165, 95% CI 76.6–88.0), followed by catamenial symptoms in 83.5% (142/170, 95% CI, 77.2–88.4) and bleeding in 50.9% (89/175, 95% CI 43.5–58.2). In the 148 women followed for a period ranging from three to 92.5 months, seven (4.7%, 95% CI 2.3–9.4) recurrences were observed. The results of this analysis show that umbilical endometriosis represents about 20% of all the abdominal wall endometriotic lesions and that over two thirds of cases are primary umbilical endometriosis forms. Pain and catamenial symptoms are the most common complaints that suggest the diagnosis. Primary umbilical endometriosis may originate from implantation of regurgitated endometrial cells conveyed by the clockwise peritoneal circulation up to the right hemidiaphragm and funneled toward the umbilicus by the falciform and round liver ligaments.

Surgical management of diaphragmatic and thoracic endometriosis': A French multicentric descriptive study

INTRODUCTION

Surgical management of Diaphragmatic and thoracic endometriosis (DTE) is still controversial, a thoracic or an abdominal approach can be proposed.

METHODS

We conducted a multicentric retrospective study in 8 thoracic, gynecology or digestive surgery units in 5 French university hospitals. The main objective was to review the current management of DTE.

RESULTS

50 patients operated for DTE from 2010 to 2017 were included: 26 with a thoracic approach and 24 with an abdominal approach. Preoperative pelvic endometriosis (PE) concerned 25 patients. In 38 patients, DTE diagnosis was made on clinical symptoms (pneumothorax (n = 19), chronic or catamenial chest pain (n = 18) or hemopneumothorax (n = 1)). Median time from onset of symptoms to diagnosis was 47 months (0-212). PE surgery concurrently occurred in 22 patients. We report diaphragmatic nodules, pleuropulmonary nodules and diaphragmatic perforations in 42, 5 and 22 women respectively. Lesions were right-sided in 45 patients. Nodules were destructed in 12 cases and resected in 38 cases. When a diaphragmatic reconstruction was needed (n = 31), a simple suture was performed in 26 patients, while 5 patients needed a mesh repair. Pleural symphysis was performed for all patients who received a thoracic approach. DTE resection was considered complete in 46 patients. Three patients had severe 30-days complications of DTE surgery. Median follow-up was 20 months (range 1-69). Recurrence occurred in 10 patients.

CONCLUSION

The results emphasize the importance of systematically looking for chest pain in patients suffering from PE and underline the lack of a standardized procedure and treatment in DTE.

Diagnosis and treatment of diaphragmatic endometriosis: results of an international patient survey

OBJECTIVES

To quantify the delays associated with the diagnosis and treatment of diaphragmatic endometriosis (DE), and to evaluate patient-reported postoperative outcomes.

STUDY DESIGN

An anonymous survey was designed to collect data regarding demographics, duration and nature of DE symptoms, type of surgery and postoperative outcomes. Members of endometriosis patient associations in 14 countries were invited to complete the survey if they had been diagnosed with DE. Factors associated with postoperative outcomes were analyzed using Mann-Whitney U and Fisher's exact tests.

RESULTS

Data was available from 136 respondents (median age 34 years). 98 % of respondents were from Europe, North America or Oceania. The most frequently reported symptoms of DE were moderate-severe pain in the upper abdomen (68 %), chest (64 %) and shoulder (54 %). Pain was right-sided in 54 %, left-sided in 11 % and bilateral in 35 %. Of 122 respondents who initially consulted a primary care physician, a gynaecology referral occurred after a median of five consultations (range 1-100). The median time between first primary care consultation and diagnosis of DE was two years (range 0-23). 31 % were diagnosed >1 year after their first gynaecology consultation (range 1-13 years), and 30 % required two or more laparoscopies before diagnosis. 116 respondents underwent surgical treatment. Postoperative data was available for 113 respondents, and 65 % reported either a significant improvement or complete resolution of symptoms. There was no significant difference in age (P = 0.19), timing of diagnosis (P = 0.59) or type of procedure (excision or ablation) (P = 0.13) between respondents who did and did not experience symptomatic relief after surgery. 61 % reported long-lasting symptomatic relief after a median of 1 year, whilst 39 % reported ongoing moderate-severe pain or have undergone further surgery for recurrent symptoms.

CONCLUSION

The diagnosis and treatment of diaphragmatic endometriosis is often delayed, due to lack of awareness by patients and healthcare professionals. The diagnosis of DE requires a high index of suspicion and involvement of surgeons trained in laparoscopic liver mobilization. Recurrent symptoms are common following surgical treatment, and international collaborative studies are required to determine the long-term outcomes of this condition.

Diaphragmatic endometriosis and thoracic endometriosis syndrome: a review on diagnosis and treatment

Endometriosis of the diaphragm has been gaining more attention in the practice of gynecologists and thoracic surgeons in recent years. Understanding related symptoms and developing imaging methods have improved their approach. A review of the literature was performed with the aim to report on incidence, diagnosis, treatment and prognosis of diaphragmatic endometriosis. We also cover the issue of the Thoracic Endometriosis Syndrome (TES). Complaints of cyclic chest pain in patients of childbearing age should have as differential diagnosis the presence of thoracic endometriosis. Catamenial pneumothorax is the main manifestation of diaphragmatic endometriosis and Thoracic Endometriosis Syndrome. Other possible manifestations are hemothorax, pulmonary nodules, and diaphragmatic hernia. Despite the possibility of drug treatment, many patients will be submitted to surgical treatment. The minimally invasive approach should be the one of choice. The robotic pathway allows for an easier approach due to its ability to articulate robotic arms, allowing the treatment of lesions in hard-to-reach locations, such as the posterior part of the diaphragm. Multidisciplinary treatment should be used in most cases, as only abdominal approach is not sufficient for the diagnosis and treatment of lesions in the thoracic cavity. The approach of endometriosis of the diaphragm and Thoracic Endometriosis Syndrome should be multidisciplinary, allowing the improvement of quality of life in most patients.

Ultrasonography and Atypical Sites of Endometriosis

In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in "atypical" sites, in all the cases where "typical" clinical findings are present.

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.

Recommendations for the surgical treatment of endometriosis. Part 2: deep endometriosis

STUDY QUESTION

How should surgery for endometriosis be performed?

SUMMARY ANSWER

This document provides recommendations covering technical aspects of different methods of surgery for deep endometriosis in women of reproductive age.

WHAT IS KNOWN ALREADY

Endometriosis is highly prevalent and often associated with severe symptoms. Yet compared to equally prevalent conditions, it is poorly understood and a challenge to manage. Previously published guidelines have provided recommendations for (surgical) treatment of deep endometriosis, based on the best available evidence, but without technical information and details on how to best perform such treatment in order to be effective and safe.

STUDY DESIGN SIZE DURATION

A working group of the European Society for Gynaecological Endoscopy (ESGE), ESHRE and the World Endometriosis Society (WES) collaborated on writing recommendations on the practical aspects of surgery for treatment of deep endometriosis.

PARTICIPANTS/MATERIALS SETTING METHODS

This document focused on surgery for deep endometriosis and is complementary to a previous document in this series focusing on endometrioma surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The document presents general recommendations for surgery for deep endometriosis, starting from preoperative assessments and first steps of surgery. Different approaches for surgical treatment are discussed and are respective of location and extent of disease; uterosacral ligaments and rectovaginal septum with or without involvement of the rectum, urinary tract or extrapelvic endometriosis. In addition, recommendations are provided on the treatment of frozen pelvis and on hysterectomy as a treatment for deep endometriosis.

LIMITATIONS REASONS FOR CAUTION

Owing to the limited evidence available, recommendations are mostly based on clinical expertise. Where available, references of relevant studies were added.

WIDER IMPLICATIONS OF THE FINDINGS

These recommendations complement previous guidelines on management of endometriosis and the recommendations for surgical treatment of ovarian endometrioma.

STUDY FUNDING/COMPETING INTERESTS

The meetings of the working group were funded by ESGE, ESHRE and WES. Dr Roman reports personal fees from ETHICON, PLASMASURGICAL, OLYMPUS and NORDIC PHARMA, outside the submitted work; Dr Becker reports grants from Bayer AG, Volition Rx, MDNA Life Sciences and Roche Diagnostics Inc. and other relationships or activities from AbbVie Inc., and Myriad Inc, during the conduct of the study; Dr Tomassetti reports non-financial support from ESHRE, during the conduct of the study; and non-financial support and other were from Lumenis, Gedeon-Richter, Ferring Pharmaceuticals and Merck SA, outside the submitted work. The other authors had nothing to disclose.

TRIAL REGISTRATION NUMBER

na.

Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management

Background:

Endometriosis is characterized by the presence of endometrial-like glands and stroma outside the uterine cavity and is believed to affect 6%–10% of reproductive-age women. Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES).

Database:

Computerized searches of MEDLINE and PubMed were conducted using the key words “thoracic endometriosis,” “catamenial pneumothorax,” “catamenial hemothorax,” and “catamenial hemoptysis.” References from identified sources were manually searched to allow for a thorough review.

Conclusion:

TES can produce incapacitating symptoms for some patients. Symptoms of TES are nonspecific, so a high degree of clinical suspicion is warranted. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected TES uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.

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.

Thoracic and diaphragmatic endometriosis: Single-institution experience using novel, broadened diagnostic criteria

Objective:

To describe our experience with the multidisciplinary management of both thoracic/diaphragmatic endometriosis (TED), applying a broadened definition of the “Thoracic endometriosis syndrome (TES)” to define cases.

Material and Methods:

We present a retrospective series of consecutive patients affected by pathology-proven TED, treated at our institution, during a period of 7 years.

Results:

Five women were included. Two patients were referred due to catamenial chest/shoulder pain, one due to recurrent catamenial pneumothorax, and one due to new-onset diaphragmatic hernia. One patient had no thoracic symptoms, but diaphragmatic endometriosis was found during gynecologic laparoscopy for pelvic endometriosis. Endometriosis was histologically confirmed in all cases. After follow-up, all patients remain asymptomatic.

Conclusion:

Broadened TES criteria could increase the incidence of TED and determine better knowledge of this condition. Multidisciplinary, minimally invasive surgery is effective and safe, but should be reserved for tertiary referral centers.

[Extragenital endometriosis: Parietal, thoracic, diaphragmatic and nervous lesions. CNGOF-HAS Endometriosis Guidelines]

According to some studies, extragenital endometriosis represents 5% of the localisations. Its prevalence seems to be underestimated. The extra pelvic localisation can make the diagnosis more difficult. Nevertheless, the recurrent and catamenial symptomatology can evoke this pathology. Surgery seems to be the unique efficient treatment for parietal lesions. Pain linked to nervous lesions (peripheric and sacral roots) seems to be underestimated and difficult to diagnose because of various localisations. Neurolysis seems to have encouraging results. Diaphragmatic lesions are often discovered either incidentally during laparoscopy, or by pulmonary symptomatology as recurrent catamenial pneumothorax or cyclic thoracic pain. Surgical treatment seems as well to be efficient.

Relationship between Catamenial Pneumothorax or Non-catamenial Pneumothorax and Endometriosis

STUDY OBJECTIVE

To evaluate the clinical characteristics of women presenting with catamenial pneumothorax and compare them with those with noncatamenial pneumothorax.

DESIGN

A case-control study (Canadian Task Force II-2).

SETTING

A multicenter study.

PATIENTS

Forty-two women with pneumothorax: 21 women had catamenial pneumothorax (study group), and 21 were age-matched women with noncatamenial pneumothorax (control group).

INTERVENTIONS

All patients underwent video-assisted thoracoscopy and pleural biopsy. We also evaluated the presence and stage of pelvic endometriosis in 16 women with catamenial pneumothorax who had undergone laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

The number of known episodes of catamenial pneumothorax before treatment was between 2 and 8 episodes. Symptoms were mainly chest pain and shortness of breath; 1 patient had hemoptysis. The prevalence of right-sided pneumothorax was 95.2% in the study group and 57.1% in the control group (p = .004). Besides 2 cases with complete collapse of the right lung, most of the cases in the study group had apical pneumothorax. Pelvic endometriosis was found in 15 of 16 women (93.7%), mainly stage 3 or 4, and thoracic endometriosis in 12 of 20 women (60%). None of the patients in the control group had thoracic endometriosis.

CONCLUSION

Thoracic endometriosis is found in over half of women with catamenial pneumothorax but absent in those with noncatamenial pneumothorax. Right apical pneumothorax is predominant in women with catamenial pneumothorax. Endometriosis plays an important role in the mechanism of catamenial pneumothorax.

Thoracic Endometriosis Syndrome: A Veritable Pandora's Box

Thoracic endometriosis syndrome is a rare disorder characterised by the presence of functioning endometrial tissue in pleura, lung parenchyma, airways, and/or encompasses mainly four clinical entities-catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and lung nodules. The cases were studied retrospectively by reviewing the records at Amrita Institute of Medical Sciences, for duration of five years i.e., form March 2010-2014 and analysed for the clinical presentation and management of thoracic endometriosis syndrome. Catamenial breathlessness was the main symptom. Pneumothorax and pleural effusion were the findings on investigations. Histopathology report of endometriosis was present in three cases (50%). Conditions with excess oestrogen like endometriosis, fibroid, adenomyosis were diagnosed in these patients by pelvic scan. After the initial supportive treatment with hormones, pleurodesis, hysterectomy and lung decortication were the treatment modalities. Two cases that had multiple recurrences were diagnosed as disseminated TES. They underwent combined treatment of surgery and hormones.

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.

MR diagnosis of diaphragmatic endometriosis

PURPOSE

To evaluate magnetic resonance imaging (MRI) for diaphragmatic endometriosis diagnosis.

MATERIALS AND METHODS

Over a 2-year period, all diaphragmatic MRI performed in the context of diaphragmatic endometriosis were reviewed. Axial and coronal fat-suppressed T1- and T2-weighted sequences were analyzed by two independent readers for the presence of nodules, plaque lesions, micronodule clustering, or focal liver herniation. MR abnormalities were correlated to surgical findings in women surgically treated. Interobserver agreement was assessed by κ statistics.

RESULTS

Twenty-three women with diaphragmatic endometriosis criteria comprised the population; 14 had surgical confirmation and nine had symptoms relief with hormonal treatment. MRI sensitivity was 83 % (19/23; 95 % confidence interval [CI]: 68, 98) for reader 1 and 78 % (18/23; 95 % CI: 61, 95) for reader 2. Kappa value was 0.86 (95 % CI: 0.47, 1.00). Readers 1 and 2 detected 35 and 36 lesions, respectively, all right-sided and agreed for 32 lesions on the type, location, and signal. Lesions were mostly nodules (23/32, 72 %), predominantly posterior (28/32, 87.5 %) and hyperintense on T1 (20/32, 63 %). MRI was negative for both readers in 2 surgically treated patients with small nodules or isolated diaphragmatic holes.

CONCLUSION

MRI allows diaphragmatic endometriosis diagnosis with 78 to 83 % sensitivity and excellent interobserver agreement.

KEY POINTS

• MRI allows the diagnosis of diaphragmatic endometriosis with up to 83 % sensitivity. • Diaphragmatic endometriosis lesions are better depicted on fat-suppressed T1-weighted sequences. • Diaphragmatic lesions, mostly hyperintense nodules, are right-sided and predominantly posterior. • MRI can help in timely diagnosis of diaphragmatic endometriosis.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

Frequently Misdiagnosed Extrapelvic Endometriosis Lesions: Case Reports and Review of the Literature

Extrapelvic endometriosis is a rare condition defined as the presence of endometriotic stroma and glands outside the pelvis and elsewhere in the body. The cervix, vagina, vulva, intestinal tract, urinary tract, diaphragm, abdominal wall, inguinal canal, thoracic cage and lungs, extremities and even the central and peripheral nervous system can be involved. Because extrapelvic endometriosis is located in unusual sites, it is often confused with other pathologic conditions. This can lead to a difficult and challenging diagnosis and management. In the presence of recurrent, cyclical and catamenial symptoms, extragenital endometriotic lesions should be suspected. The aim of our paper is to report 9 cases of rare locations of extrapelvic endometriosis and to provide a literature review.

Video-assisted laparoscopy for the detection and diagnosis of endometriosis: safety, reliability, and invasiveness

Endometriosis is a highly enigmatic disease with multiple presentations ranging from infertility to severe pain, often causing significant morbidity. Video-assisted laparoscopy (VALS) has now replaced laparotomy as the gold standard for the diagnosis and management of endometriosis. While imaging has a role in the evaluation of some patients, histologic examination is needed for a definitive diagnosis. Laboratory evaluation currently has a minor role in the diagnosis of endometriosis, although studies are underway investigating serum markers, genetic studies, and endometrial sampling. A high index of suspicion is essential to accurately diagnose this complex condition, and a multidisciplinary approach is often indicated. The following review discusses laparoscopic diagnosis of endometriosis from the pre-operative evaluation of patients suspected of having endometriosis to surgical technique for safe and adequate laparoscopic diagnosis of the condition and postsurgical care.

Pericardial, pleural and diaphragmatic endometriosis in association with pelvic peritoneal and bowel endometriosis: a case report and review of the literature

Diaphragmatic endometriosis is a rare entity, often asymptomatic, which has been described only in small series. It is almost always associated with severe pelvic involvement. The most plausible theory about this condition is based on retrograde menstruation and subsequent transportation of viable cells in peritoneal fluid from the pelvis up the right gutter to the right hemidiaphragm, thus demonstrating its asymmetric distribution on the diaphragm. Pre-operative diagnosis is poorly supported by imaging techniques. In most cases, it is an incidental finding because the lesions may hide behind the right hepatic lobe. In that case it cannot be easily demonstrated with a laparoscope from an umbilical port. Symptomatic diaphragmatic endometriosis is associated with deep lesions which can involve the entire thickness of the diaphragm. In these cases, treatment is more difficult with possible incomplete pain relief and a considerable possibility of recurrence. In this subset, abdominal surgery is recommended. Surgical treatment must be individualized on the basis of the patient's age, fertility desires, type and location of disease and symptoms. We report the surgical treatment of a patient with synchronous pericardial, pleural and diaphragmatic endometriosis associated with pelvic peritoneal and bowel involvement. A review of the literature regarding pericardial and diaphragmatic endometriosis focusing on anatomical and surgical aspects of its management is undertaken.

Extragenital endometriosis

In recent years, there have been significant changes in many aspects of extragenital endometriosis ranging from the epidemiology to the management of the disease. Advances in minimally invasive surgery and expansion of the field have lead to further research in management of extragenital endometriosis. As a result, treatment has shifted from medical management toward a surgical, multidisciplinary approach. Surgery for extragenital endometriosis clearly improves outcome through relief of symptoms, improved quality-of-life, increased fertility rates, and reduced recurrences. Endoscopy has a pivotal role as both a diagnostic and therapeutic tool.

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.

Tumors of the diaphragm

Primary tumors of the diaphragm are rare. The most common benign cystic lesions of the diaphragm are bronchogenic or mesothelial cysts, while the most common benign solid lesion is a lipoma. Benign tumors of the diaphragm are resected if they are symptomatic or if there is a doubt about the diagnosis. The most common primary malignant lesion is rhabdomyosarcoma. Malignant tumors are treated based on histology and often with chemotherapy and/or radiation along with surgical resection if feasible. Endometriosis, a benign process that metastasizes to the diaphragm, is typically treated medically; surgical ablation or resection is considered only after failed conservative treatment. Surgical resection of metastatic malignant tumors, such as ovarian cancer and thymoma, as well as malignancies affecting the diaphragm by direct extension, such as mesothelioma, lung, and esophageal cancer, may provide some survival advantage.

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.

[Pneumothorax in women and thoracic endometriosis]

Thoracic endometriosis has been considered a rare clinical condition but it is probably underestimated in the literature. Various clinical symptoms may occur but the most frequent are catamenial pneumothoraces. Four main clinical conditions may reveal thoracic endometriosis: catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and endometrial nodules in the lung. Catamenial pneumothoraces are the most frequent manifestation, characterized, in the majority of the cases, by right side localization and diaphragmatic abnormalities (perforations and/or nodules). The resection of suspected areas of visceral or parietal pleural endometriosis, as well as partial resection of the diaphragm in the case of nodules and/or perforations, allows the histological diagnosis of endometriosis. Because of the high recurrence rate, treatment of catamenial pneumothoraces should combine surgery and hormonal therapy.

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

OBJECTIVE

To explore diaphragmatic lesions that are potentially associated with catamenial pneumothorax by using an advanced flexible laparoscope with wide optic angle.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 30-year-old woman who was scheduled for thoracoscopic surgery because of recurrent right-sided catamenial pneumothorax.

INTERVENTION(S)

The peritoneal surface of the diaphragm was explored with an advanced flexible laparoscope that was equipped with a charge-coupled device on the tip, concurrently with thoracoscopic surgery.

MAIN OUTCOME MEASURE(S)

Lesions associated with endometriosis on the peritoneal surface of the posterior diaphragm abutting the posterior abdominal wall and liver.

RESULT(S)

When the flexible laparoscope was inserted via an umbilical trocar and the peritoneal surface of the right-sided diaphragm was explored, guided by illumination from the thoracoscope, scattered specific lattice lesions and fenestrations were identified in the central tendon of the posterior diaphragm, a region that cannot be visualized with the conventional rigid laparoscope.

CONCLUSION(S)

By using the flexible laparoscope, endometriotic lesions potentially related to catamenial pneumothorax were identified on the posterior diaphragm.

L'endométriose extragénitale

Parietal, appendiceal, pleuropulmonary and diaphragmatic endometriosis represent 5% of endometriosis cases. Diagnosis and management of these extra-genital localisations are described according to the literature. Parietal endometriosis usually requires large resection of the tumor. Appendiceal endometriosis is frequently observed in cases of digestive endometriosis. Induration or rigidity of the appendix due to the presence of deep infiltrating endometriosis justifies appendicectomy. Thoracic and diaphragmatic endometriosis is characterized by the presence of typical symptoms during the perimenstrual periode. Medical treatment obtaining therapeutic amenorrhea is firstly administered and surgery is indicated in cases of symptoms recurrence.