Diaphragmatic endometriosis: diagnosis and surgical management--a case report

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.

Utility of diffusion weighted imaging in diagnosing subdiaphragmatic endometriosis presenting as shoulder pain

Extrapelvic endometriosis (EPE) is a rare entity which may potentially occur at any site. Symptomatic EPE is now increasingly being managed laparoscopically. Imaging is imperative in diagnosis as well as extent delineation prior to surgery. In addition to increasing the success rate of diagnostic laparoscopy, prior knowledge of EPE at certain sites may modify the standard surgical technique. We present here an unusual case of chronic pain in the right shoulder in a 26-year-old female caused by subdiaphragmatic endometriosis (SDE). It was noticed on conventional magnetic resonance imaging (MRI) sequences; however, due to the lack of the characteristic signal intensity, imaging findings were noncontributory. Diffusion-weighted imaging (DWI) facilitated its characterization and precisely mapped the extent of involvement. SDE should be suspected in young females presenting with cyclical shoulder pain. Due to nonspecific clinical features, it may remain undiagnosed. MRI is the imaging modality of choice in evaluation of EPE. Including DWI sequence in the MR protocol increases the diagnostic precision besides delineating the extent of involvement noninvasively.

The importance of early diagnosis and treatment of incidental tension pneumothorax during robotic assisted laparoscopy for diaphragmatic endometriosis: a report of two cases

We describe two cases of diaphragmatic endometriosis treated using the robotic assisted laparoscopic approach, in which an incidental tension pneumothorax occurred during the initial inspection and assessment of diaphragmatic lesions. We demonstrate the importance of early diagnosis of this complication and report successful resolution using the thoracic drainage technique. In case one, after the pneumoperitoneum was installed, during the cavity assessment and inspection, small endometriotic lesions were observed in the tendon portion of the diaphragmatic surface. We observed a sudden increase in maximum airway pressures and a reduction in tidal volume, associated with arterial hypotension and hemodynamic instability and bulging of the diaphragm, which led to the diagnosis of a tension pneumothorax. In case two, diaphragmatic endometriotic lesions were also observed after hepatic mobilisation and following visualisation of the endometriotic lesions, an abrupt decrease in the capnography values was observed, consistent with hypertensive pneumothorax. In both cases, even after deflation of the abdominal cavity, hemodynamic instability persisted. We treated both cases with thoracic drainage, which immediately normalised respiratory parameters and resulted in hemodynamic stabilisation, and the surgical procedures were continued. During laparoscopic procedures for the treatment of diaphragmatic endometriosis, the endometriotic lesions can behave as communication hole in the tendon portion of the diaphragmatic surface and the changes in ventilatory patterns and haemodynamic instability should alert the medical team to the development of an incidental tension pneumothorax. The early identification of this complication in both cases allowed rapid intervention for chest drainage and allowed the surgical procedure to continue.

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.

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.