Endométriose du diaphragme. Aspects diagnostiques à propos d'un cas sans pneumothorax

doi:10.1016/0248-8663(96)80749-1

La Revue de Médecine Interne

Volume 16, Issue 7, July 1995, Pages 527-532

https://doi.org/10.1016/0248-8663(96)80749-1 Get rights and content

Résumé

L'atteinte diaphragmatique est une localisation rare de l'endométriose. Dans la littérature elle se révèle le plus souvent par un pneumothorax cataménial. Nous rapportons l'observation d'une femme de 21 ans souffrant d'une névralgie phrénique depuis 18 mois. Motivée par des signes ultérieurs d'endométriose pelvienne, la cœlioscopie découvre de minces lésions endométriosiques sur la face abdominale du diaphragme. Nous évoquons les rares observations similaires de la littérature. Elles confirment l'intérêt limité de l'imagerie pour ce diagnostic qui n'est pas posé avant la découverte de lésions pelviennes. En vue d'un diagnostic plus précoce, nous rappelons les causes de névralgies phréniques. Leur analyse permet de dégager des arguments en faveur d'une cœlioscopie. La pratique plus courante de cet examen éclaircira les mécanismes évolutifs de cette forme d'endométriose.

Summary

Diaphragmatic disease is a rare manifestation of endometriosis. In the literature it is most often revealed by cataménial pneumothorax. We describe the case of a 21-year old woman presenting with tight-sided phrenic neuralgia, lasting 18 months. Signs of pelvic endometriosis appearing later on, laparoscopy showing thin lesions of endometriosis on the diaphragmatic undersurface. We review the few similar cases described earlier. They confirm that imaging studies are of little value, the diagnosis being made only after the discovery of pelvis disease. Our study of the multiple causes of phrenic neuralgia allows to establish criteria indicating when laparoscopy is warranted. Increasing practice of this test will shed light on the natural history of diaphragmatic endometriosis.

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Cited by (16)

Laparoscopic En Bloc Right Diaphragmatic Peritonectomy for Diaphragmatic Endometriosis According to the Sugarbaker Technique
2016, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Therefore, DE is usually incidentally detected during laparoscopic surgery for severe deep infiltrating endometriosis, and it is crucial for trained laparoscopists to accurately deal with these uncommon findings, which can represent a complex therapeutic challenge. In fact, it has to be considered that even if medical approaches can ensure potential benefits, the failure rate of this therapeutic approach remains non-negligible [10,18]. Therefore, it is not surprising that the vast majority of patients in our series and previously published series have failed several medical treatments before receiving surgery [2,3].
To evaluate the feasibility of a novel laparoscopic procedure for complete eradication of diaphragmatic endometriosis (DE).
A retrospective multicenter study (Canadian Task Force Classification II-2).
University tertiary referral centre.
A consecutive series of 9 women with DE.
Laparoscopic en bloc eradication using Sugarbaker's peritonectomy technique with or without diaphragmatic resection for DE. All surgical procedures were performed by the same surgeon in 2 tertiary referral centers (Charitè University, Berlin, Germany, and Catholic University of the Sacred Heart, Foundation John Paul II, Campobasso, Italy).
Rate of conversion to laparotomy, perioperative outcomes, intra- and postoperative complications, and recurrence rate. The procedures were successfully performed in all patients laparoscopically without conversion to laparotomy. All patients also presented with multiple endometriotic lesions in the Morison pouch, and in 3 cases a deep infiltration of the right diaphragm was observed that required partial diaphragmatic resection. In 2 women, pulmonary nodules were also detected, and lung laparoscopic resection was attempted to eradicate the disease. A chest drain was placed in 7 women and was removed after a median time of 6 days (range, 4–10 days). No intra- or postoperative complications were recorded. To complete the diaphragmatic peritonectomy, the median operative time required was 180 minutes (range, 90–240 minutes). The median estimated blood loss was 100 mL (range, 50–300 mL), and the median hospital stay was 10 days (range, 5–17 days). After a median follow-up of 6 months, we observed symptomatic relief for all study patients without major surgery-related morbidity. In 1 woman, laparoscopic adhesiolysis was performed after 18 months from surgery without signs of recurrent endometriosis.
Laparoscopic en bloc eradication of DE with Sugarbaker's peritonectomy is highly effective in the management of symptomatic DE, with no major intra-/postoperative complications and very favorable perioperative outcomes.
Catamenial pneumothorax with diaphragmatic lacerations
2010, Revue de Pneumologie Clinique
Les auteurs rapportent un cas de pneumothorax cataménial, associé à des défects majeurs du centre phrénique du diaphragme, au niveau desquels s’herniait partiellement le dôme hépatique. Il s’agit d’une présentation rare du pneumothorax cataménial, car le plus souvent les perforations sont millimétriques ou centrimétriques. Nous analysons les difficultés du diagnostic et la stratégie chirurgicale.
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.
Laparoscopic Approach to Right Diaphragmatic Endometriosis with Argon Laser: Case Report
2010, Journal of Minimally Invasive Gynecology
Citation Excerpt :
Symptomatic endometriosis of the diaphragm is challenging not only because diagnosis requires a high index of suspicion but also because its treatment remains a matter of debate and individualization is mandatory. Noninvasive medical therapy has rarely yielded successful results [5,6]. Witte and Guilbaud [6] reported a patient treated with GnRH agonist who even developed new lesions during this therapy, and Redwine [5] reported 8 additional similar cases that did not benefit from preoperative GnRH analog treatment.
Diaphragmatic involvement by an endometriotic cyst is a rare entity that may be responsible for chronic thoracic pain. Herein we present a case report of a 6-cm right diaphragmatic endometrioma treated using laparoscopic partial excision and argon laser coagulation of the inner cyst wall. The laparoscopic approach to upper abdomen endometriosis is feasible and safe when accurate evaluation of the case is performed.
Endometriosis of the Diaphragm: Four Cases Treated with a Combination of Laparoscopy and Thoracoscopy
2009, Journal of Minimally Invasive Gynecology
We aim to describe the clinical characteristics and the principles of combined laparoscopic and thoracoscopic management of women with diaphragmatic endometriosis at our institution.
Case series (Canadian Task Force Classification II2).
Tertiary care referral center.
Four women with diaphragmatic endometriosis.
Laparoscopy and thoracoscopy.
We retrospectively reviewed the charts of 4 consecutive women with diaphragmatic endometriosis who underwent laparoscopy and thoracoscopy from June 2008 through September 2008.
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.
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.
Thoracic endometriosis
2007, Revue des Maladies Respiratoires
Le terme « endométriose thoracique » désigne les manifestations respiratoires liées classiquement à la présence et aux modifications cycliques de tissu endométrial dans l’une des structures du thorax.
L’endométriose thoracique regroupe quatre entités cliniques bien reconnues : pneumothorax, hémothorax, hémoptysie et nodule pulmonaire (respectivement 73 %, 14 %, 7 % et 6 % des cas). Leur point commun est la répétition des symptômes lors des règles chez des femmes habituellement entre 30 et 40 ans, et une atteinte prédominante de l’hémithorax droit. Une endométriose pelvienne est le plus souvent, mais non systématiquement, associée. Le pneumothorax cataménial n’est pas toujours dû à une endométriose thoracique et ses mécanismes restent méconnus. Un traitement chirurgical est justifié par la fréquence des récidives sous traitement médical seul. La vidéo-thoracoscopie est actuellement la technique de choix permettant de visualiser au mieux des anomalies pleuro-diaphragmatiques pathognomoniques présentes dans environ un tiers des cas. Le geste consiste à réparer les fentes diaphragmatiques et à exciser toutes les lésions d’endomètriose visibles et il sera éventuellement complété par une abrasion pleurale. L’association avec une hormonothérapie prolongée est de plus en plus préconisée, en privilégiant le Danazol ou les analogues de la GnRH.
De futures études prospectives devraient permettre de mieux apprécier l’incidence réelle de l’endométriose thoracique et de définir l’approche thérapeutique optimale.
L’endométriose thoracique est une maladie probablement rare mais dont le diagnostic est aisé lorsqu’on sait l’évoquer devant des manifestations cliniques variées. Sa prise en charge est multidisciplinaire et fait intervenir pneumologue, chirurgien thoracique et gynécologue.
Endometriosis is defined as the abnormal presence of endometrial tissue, including endometrial glands and stroma, outside the uterine cavity. The term “thoracic endometriosis” is classically referred to the respiratory manifestations which classically result from the presence and the cyclical changes of endometrial tissue in one of the thoracic structures.
Although thoracic endometriosis is rare, four clinical entities are well-recognized: pneumothorax, hemothorax, haemoptysis and pulmonary nodule, with a respective frequency of 73%, 14%, 7% and 6%. These are characterized by the recurrence of symptoms within the menstruations, in women aged between 30 and 40, and mainly in the right hemi-thorax. Pelvic endometriosis is usually, if not constantly, associated. Catamenial pneumothorax is not always related to thoracic endometriosis and its mechanisms remain unclear. An exploratory and therapeutical surgery is required in most of the cases. Video-assisted-thoracoscopy is the best current approach of catamenial pneumothorax. It may visualize pathognomonic pleuro-diaphragmatic abnormalities, including diaphragmatic fenestrations and/or endometrial implants, in about one third of the patients. Surgical treatment is justified because of the frequent relapses under medical treatment alone. Surgery consists of diaphragmatic repair and excision of all apparent endometrial implants; pleural abrasion may complete the procedure. A combined prolonged hormonal therapy is increasingly recommended, Danazol or GnRH analogs being advantaged.
Further prospective studies are needed to estimate the real incidence of thoracic endometriosis and to devise the best therapeutical option.
Thoracic endometriosis is probably rare but its diagnosis is easy when accurately raised. The approach is multidisciplinary involving a pneumologist, a thoracic surgeon and a gynecologist.
Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment
2002, Fertility and Sterility
Objective: To describe symptoms, surgical diagnosis and treatment, and long-term outcome of patients with symptomatic diaphragmatic endometriosis.
Design: Observational follow-up study.
Setting: American tertiary referral center for the surgical treatment of endometriosis.
Patient(s): Eight patients with diaphragmatic endometriosis causing severe or disabling symptoms.
Intervention(s): Laparoscopic diagnosis of diaphragmatic endometriosis followed by upper abdominal laparotomy for full-thickness resection of the diaphragm.
Main Outcome Measure(s): Reduction of several symptoms as measured on a 5-point ranked ordinal scale administered by a phone survey up to 7 years after surgery.
Result(s): Laparoscopy from an umbilical port may identify small “sentinel lesions” of endometriosis on the anterior or mid diaphragm. Eight symptomatic patients all had significant invasive disease with dimensions up to 5 cm across of the posterior right diaphragm, which could not always be seen from the umbilical port site. All such lesions can be seen by a laparoscope placed beneath the right costal margin. Laparoscopic treatment of symptomatic disease is not rational given the posterior placement of the disease out of sight behind the liver and the full-thickness nature of the disease in all eight patients. Laparotomy with full thickness resection of the diaphragm resulted in complete eradication of symptoms in seven of eight patients, and good symptomatic reduction in one.
Conclusion(s): Treatment of diaphragmatic endometriosis by laparotomy results in a high rate of symptom relief. Laparoscopic treatment of diaphragmatic endometriosis will result in a high rate of incomplete diagnosis and incomplete treatment with a high rate of continuing symptoms.

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Endométriose du diaphragme. Aspects diagnostiques à propos d'un cas sans pneumothoraxEndometriosis of the diaphragm. Diagnostic features of a case without pneumothorax

Résumé

Summary

Clin Neurol Neurosurg

J Auton Nerv Syst

Fertil Steril

Laparoscopy in the management of pelvic pain in adolescents

J Reprod Med

Endometriosis

N Engl J Med

Endométriose et brèche diaphragmatique dans le pneumothorax cataménial

Ann Chir

Catamenial pneumothorax

Nippon Kyobu Shikkan Gakkai Zasshi

An experience of surgical treatment for catamenial pneumothorax with diaphragmatic and pulmonary endometriosis

Kyobu Geka

Referred shoulder pain. An elusive diagnosis

Postgrad Med