Spontaneous pneumothorax resulting from pneumoperitoneum therapy

Porous diaphragm syndrome with repeated rapid accumulation of pleural effusion

A 53-year-old woman was admitted with right massive transudative pleural effusion and acute renal failure. The amount of pleural fluid reduced in response to treatment with hydration and diuretics; however, the effusion recurred one month later. We suspected the presence of a right pleuroperitoneal communication allowing pleural fluid to accumulate from an origin of ascites triggered by renal failure. Chest computed tomography following pleural drainage revealed a small nodule in the right upper lobe of the lung. A diagnosis of T1aN0M0 lung adenocarcinoma was made based on the results of various examinations, including bronchoscopy. Video-assisted thoracoscopic surgery was performed, and the presence of a small hole communicating between the pleural and peritoneal cavities was confirmed in the right diaphragm during the surgery.

[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.

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.

Pneumothorax associated with laparoscopic cholecystectomy

Pneumothorax is an uncommon but potentially serious complication that can occur during laparoscopic procedures. A patient under-going laparoscopic cholecystectomy developed an 80% pneumothorax during the course of the procedure and required chest tube insertion. She then underwent an uneventful recovery. The etiology of this complication as well as methods for avoiding this problem have been reviewed. Because of the potential serious nature of this complication, it is imperative that the surgeon be aware of the possibility and implement appropriate immediate therapy.

Case report: hepatic hydrothorax without ascites

Pleural effusion due to hepatic cirrhosis and ascites is well known. We describe three patients with right-sided hepatic hydrothorax in the absence of ascites. The formation of pleural fluid in these patients is probably a result of fluid movement from peritoneal to pleural space across diaphragmatic defects before ascites can form. The differential diagnosis of a right-sided transudative pleural effusion in a patient with chronic liver disease with or without ascites includes congestive left ventricular failure and nephrotic syndrome. These diseases are usually ruled out with standard clinical tests. Patients with hepatic hydrothorax should be treated with fluid restriction and diuretics. Patients with severe symptoms due to refractory hepatic hydrothorax might benefit from pleural sclerosis and surgical closure of diaphragmatic defects.

Catamenial pneumothorax

Five patients with catamenial pneumothorax are reported, four of whom had proven diaphragmatic defects. Two had microscopic diaphragmatic endometrial implants in the area of the defects. No specimen was obtained in two others. A fifth patient with the condition, as well as with extensive pelvic endometriosis, was treated successfully by closed thoracostomy followed by hysterectomy and salpingo-oophorectomy. Patients with recurrent catamenial pneumothorax should be assumed to have diaphragmatic defects and be considered for treatment by thoracotomy and closure of these defects if the severity of the condition warrants it.