Diaphragmatic laceration, partial liver herniation and catamenial pneumothorax

A surgical series on endometriosis-related diaphragmatic hernia

BACKGROUND

Thoracic endometriosis syndrome gives rise to various clinical and radiological manifestations. We reviewed the records of patients operated for intrathoracic migration of abdominal viscera through a diaphragmatic hernia secondary to thoracic endometriosis.

METHODS

We retrospectively reviewed the single-center prospective collected database of all patients operated for thoracic endometriosis during the twenty years. All cases in which an abdominal organ was found to be herniated into the thoracic cavity were retrieved. Clinical and pathological data are presented and analyzed.

RESULTS

Twenty women of median age 36 (range 25-58) years were operated for endometriosis-related diaphragmatic hernia. The hernia was diagnosed concomitantly with endometriosis-related pneumothorax in 13 cases and during the exploration of catamenial thoracic pain in seven cases. There were 18 cases on the right side and two cases on the left side. The median diameter of the hernia was 8 cm (2.5-20 cm). In seventeen cases, the hernia was repaired by direct suture, and in three cases a heterologous prosthesis was positioned. At follow-up, two patients had an episode of recurrent pneumothorax.

CONCLUSIONS

Diaphragmatic hernia should be ruled out in the presence of endometriosis-related pneumothorax or catamenial thoracic pain. Surgery is indicated to make a pathological diagnosis, restore anatomy, and prevent recurrence in patients presenting with 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.

Catamenial pneumothorax with partial liver herniation due to diaphragmatic laceration: a case report and literature review

BACKGROUND

Catamenial pneumothorax is generally uncommon, with an incidence of less than 3-6% in women with spontaneous pneumothorax. As few cases of catamenial pneumothorax with diaphragmatic defect and liver herniation have been reported, this case report may be useful for understanding the cause and treatment. This case highlights the importance of the approach for liver hernia in patients with catamenial pneumothorax and endometriosis.

CASE PRESENTATION

We report a case of catamenial pneumothorax in a 43-year-old woman with diaphragmatic partial liver hernia who was treated with thoracoscopic surgery. She was diagnosed with a right pneumothorax at menstruation onset. Chest computed tomography showed a nodule protruding above the right diaphragm. We performed thoracoscopic surgery to treat the persistent air leak and biopsied the nodule on the right diaphragm. There were blueberry spots on the diaphragm; the nodule was found to be the herniated liver. The diaphragmatic defect was sutured. Histological examination of the tissue near the partial prolapsed liver revealed endometrial tissue.

CONCLUSIONS

It is speculated that ectopic endometrial tissue in the diaphragm will periodically necrose to become a diaphragmatic tear, which is a pathway for air to enter the thoracic cavity and eventually a herniated liver. Thoracoscopic surgery should be considered in patients with catamenial pneumothorax when a diaphragmatic lesion is suspected.

Innovative and Contemporary Interventions of Diaphragmatic Disorders

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Large Spontaneous Right Catamenial Pneumothorax with Diaphragmatic Defect and Liver Herniation

Catamenial pneumothorax is a spontaneous pneumothorax that occurs predominantly women of child bearing age. We describe a case of a 40-year-old nulliparous woman with medical history significant for endometriosis who presented with severe chest tightness of one-day duration. Chest radiography (CXR) showed a large right spontaneous pneumothorax, what was thought to be a 5.6 cm pleural mass at the right lung base. Following pneumothorax diagnosis, the patient underwent emergent right thoracostomy with pigtail catheter placement. A repeat CXR revealed marked re-expansion of the lung but persistence of a right pleural mass. Follow up computed tomography scan of the chest showed a 33 mm diaphragmatic defect with 5.8 x 4.6 x 3.9 cm area of herniated liver corresponding to the presumed pleural mass. Following complete thoracic imaging, patient underwent video-assisted thoracoscopic surgery, mechanical pleurodesis, and open repair of the right diaphragmatic defect. Intraoperatively, an endometrial implant was noted on the chest wall. On postoperative day three, she began her menstrual cycle and was evaluated by gynecologist who recommended hormonal therapy to reduce risk of recurrent pneumothorax. Due to a persistent air leak, the chest tube was transitioned to a Heimlich valve to facilitate home discharge. The patient was discharged on postoperative day eight, seen as outpatient with resolution of air leak and removal of chest tube.

Clinical presentation and treatment of catameinal pneumothorax and endometriosis-related pneumothorax

Introduction: Catamenial pneumothorax (CP) is defined as a recurrent spontaneous pneumothorax occurring in females of reproductive age. In the 'perimenstrual period,' it is still considered relatively rare although accounting for 20-35% of spontaneous pneumothoraces occurring in premenopausal women. It is the most frequent manifestation of thoracic endometriosis, which can also cause pneumothorax during the intermenstrual period (TER non-CP). Areas covered: In this article, we review and comment the clinical presentation, etiopathogenesis, diagnostic criteria, and therapeutic management of CP and TER non-CP. We particularly emphasize on the surgical optimal treatment and associated multidisciplinary care and follow-up. Electronic databases, mostly PubMed, were used for searching terms including 'catamenial pneumothorax' and 'thoracic endometriosis.' Expert commentary: Clinical presentation and imaging of CP and TER non-CP are often unspecific except for possible visualization of endometriosis foci or diaphragmatic lesions at computed tomography-scan or magnetic resonance imaging. Thus, we recommend careful interrogatory and intraoperative inspection for appropriate diagnosis and treatment of pneumothorax in women. Despite better awareness of surgical teams, CP and TER-non CP are still associated with high rates of postoperative recurrence (around 30%). We strongly advocate for a multidisciplinary management including early surgical and chemical pleurodesis, resection of all visible endometriosis-related lesions, hormonal blockade, and prolonged follow-up.

[Pneumothorax catamenial: results of 18 cases operas]

L'objectif de notre étude était de proposer une approche thérapeutique du pneumothorax cataménial à partir des résultats de nos 18 cas opérés. Il s'agit d'une étude rétrospective de Janvier 1994 à Décembre 2016 qui a concerné 18 patientes âgées en moyenne de 32,2 ans opérées d'un pneumothorax cataménial droit (16 cas) et bilatéral (2 cas). Les patientes ont été réparties en 3 groupes en fonction de l'évolution dans le temps de notre attitude chirurgicale: le groupe 1 (G1) de janvier 1994 à juin 2006, le groupe 2 (G2) de juillet 2006 à février 2008 et le groupe 3(G3) de mars 2008 à décembre 2016, ces groupes contenaient respectivement 5, 2 et 11 patientes. Ces patientes toutes nullipares avaient une dysménorrhée depuis la puberté associée dans 11 cas à des douleurs thoraciques cataméniales. La radiographie standard du thorax a été systématique et complétée dans 8 cas par un scanner thoracique qui a objectivé en plus du pneumothorax, des bulles apicales (5 cas). L'exploration par mini thoracotomie postéro-latérale (16 cas) et par vidéothoracoscopie (2 cas de G3) a retrouvé des fenestrations diaphragmatiques (18 cas) et des bulles (5 cas). La biopsie des lésions et la résection des bulles a été systématique. Vis-à-vis des fenestrations diaphragmatiques, la chirurgie a consisté dans le groupe 1 en une résection-suture avec abrasion pleurale, dans le groupe 2 une couverture par un patch de Gore-tex avec abrasion pleurale et dans le groupe 3 une couverture par un patch avec talcage pleural. Une hormonothérapie (triptoreline) de 6 mois a été prescrite à chaque patiente en postopératoire pour suspendre les menstrues. Le résultat de la chirurgie a été apprécié sur la base de la survenue ou non d'une récidive du pneumothorax à la reprise des menstrues. La mortalité a été nulle. Le séjour hospitalier post opératoire moyen était de 9,32 jours. Les examens anatomopathologiques ont confirmé l'endométriose thoracique dans 9 cas. Après un suivi moyen de 5,3 ans, le résultat était bon chez 12 patientes (3/5 de G1, 1/2 de G2 et 8/11 de G3), 3 patientes de G3 ont continué de présenter des épisodes de dyspnée minime au début de quelques menstrues sans récidive radiologique, 3 patientes (2 de G1 et 1 de G2) ont récidivé et ont fait l'objet de reprise chirurgicale. En cas de pneumothorax cataménial avec fenestrations diaphragmatiques, nous proposons une phrénoplastie de recouvrement au patch associée à un talcage pleural et une hormonothérapie complémentaire concomitante de 6 mois.

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.

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.

Beware the 'raised right hemidiaphragm' in a female patient with previous pneumothorax surgery: liver herniation through a massive endometrosis-related diaphragmatic fenestration

A 44-year-old non-smoking woman presented with recurrent right spontaneous pneumothorax 9 years after a right-side surgical pleurodesis via a video-assisted thoracic surgery (VATS) approach for suspected primary pneumothorax in another center. Histological examination of tissue excised during the earlier operation confirmed catamenial pneumothorax, but no further treatment was given. During the 9 years since, she had had persistent right lower chest pain and chest X-ray (CXR) had shown a "persistently elevated right diaphragm", but these had been treated as iatrogenic neuropathic pain and phrenic nerve palsy respectively. A redo right surgical exploration was performed for the current recurrence. Intra-operatively, the right half of the liver was found to have herniated into the chest via a massive fenestration (10 cm × 9 cm) in the right hemidiaphragm. The defect was repaired via a combined thoracotomy and laparotomy approach. This case serves as an advisory that in patients with persistent ipsilateral chest pain and a raised hemidiaphragm following surgery for catamenial pneumothorax, diaphragmatic fenestration and abdominal visceral herniation should be suspected amongst the differential diagnoses.

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.

Thoracic endometriosis syndrome: CT and MRI features

Thoracic endometriosis is considered to be rare, but is the most frequent form of extra-abdominopelvic endometriosis. Thoracic endometriosis syndrome affects women of reproductive age. Diagnosis is mainly based on clinical findings, which can include catamenial pneumothorax and haemothorax, non-catamenial endometriosis-related pneumothorax, catamenial haemoptysis, lung nodules, and isolated catamenial chest pain. Symptoms are typically cyclical and recurrent, with a right-sided predominance. Computed tomography (CT) is the first-line imaging method, but is poorly specific; therefore, its main role is to rule out other pulmonary diseases. However, in women with a typical clinical history, some key CT findings may help to confirm this often under-diagnosed syndrome. MRI can also assist with the diagnosis, by showing signal changes typical of haemorrhage within diaphragmatic or pleural lesions.

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.

[Catamenial pneumothorax with diaphragmatic lacerations]

The authors describe a case of catamenial pneumothorax with diaphragmatic lacerations and partial liver herniation. It's a rare presentation of catamenial pneunmothorax. We analyse the diagnostic and surgical therapeutic.

[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: a case report and review of the literature

A 39-year-old woman presented with the chief complaint of right-sided chest pressure and shortness of breath with dry cough for 3 days. These symptoms coincided with the onset of her menstrual cycle. Her physical examination was significant for decreased breath sounds at the right lung base. Her chest x-ray showed a moderate sized right pneumothorax extending from the apex to the lung base and a small amount of pleural fluid, findings that were verified by chest CT. The patient was seen by consultants from the pulmonary, obstetrics/gynecology, and thoracic surgery services, who agreed that the clinical diagnosis was catamenial pneumothorax, probably associated with thoracic endometriosis. The patient was discharged on levonorgestrel/ethinyl estradiol tablets, which she opted not to take. Three months later, she had similar symptoms that occurred again at the time of menstruation. Her chest x-ray now showed a 10% right-sided pneumothorax. Catamenial pneumothorax is a rare condition affecting women in their reproductive years. Women with this condition most commonly have right-sided pneumothorax. The proper diagnosis is based on being aware of the existence of this relatively rare condition and relating the symptoms of pneumothorax temporally to the menses.