Redwine, D. B. (2002). Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertility and Sterility, 77(2), 288-296. https://doi.org/10.1016/s0015-0282(01)02998-3
Redwine DB. Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment. Fertil Steril. 2002;77(2):288-296. doi:10.1016/s0015-0282(01)02998-3
Redwine, David B. "Diaphragmatic endometriosis: diagnosis, surgical management, and long-term results of treatment." Fertility and Sterility, vol. 77, no. 2, 2002, pp. 288-296.
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Diaphragmatic endometriosis resection ended symptoms in 7 of 8 women
Full-thickness resection of the diseased section of diaphragm ended symptoms in 7 of 8 women with diaphragmatic endometriosis. The eighth woman improved. One surgeon at one American referral center reported these cases. A nurse phoned the women 1.1 to 7 years after surgery.
Key Findings
Complete elimination of symptoms was documented in seven of eight women after full-thickness resection of the diaphragm. The eighth had good symptomatic reduction.
Sentinel lesions of the anterior diaphragm, each less than 1 cm across, appeared in five of eight women (63%). The symptomatic lesions on the posterior diaphragm measured 1 to 5 cm each.
Discoloration of the pleural surface appeared in 100% of the eight symptomatic women. The diaphragm sections removed measured 6 cm to 12 cm in maximal surface dimension.
Six of the eight women had tried oral contraceptives before surgery. The author reports medical therapy was not successful in the patients who received it before resection.
One woman had bilateral pleural effusions after surgery, treated with thoracentesis. Mean laparotomy time for diaphragmatic disease was 64 minutes in five women with separate timing.
Interpretation
This case series followed eight women with diaphragmatic endometriosis. A tertiary referral center treated them by laparotomy. General surgeons performed the resections, with the author assisting. He argues that laparoscopy from the umbilicus could miss posterior diaphragm disease, since the symptomatic lesions in this series sat on the posterior surface. One laparoscopic attempt tore the liver capsule without harm. The findings support larger studies of full-thickness diaphragm resection for endometriosis.
RRM Context
In restorative reproductive medicine, excision is the surgical standard for endometriosis. The diaphragm follows the same logic. Full-thickness removal takes out the diseased tissue. The author states that medical therapy does not eradicate endometriosis. He cautions that thermal ablation may be unsafe, since the diaphragm is only 1 to 5 mm thick. All eight women also had pelvic or bowel endometriosis, treated under the same anesthetic.
Our editorial summary of this paper, not the article's abstract.
Abstract
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.
Patients
Eight patients with diaphragmatic endometriosis causing severe or disabling symptoms.
Interventions
Laparoscopic diagnosis of diaphragmatic endometriosis followed by upper abdominal laparotomy for full-thickness resection of the diaphragm.
Main Outcome Measures
Reduction of several symptoms as measured on a 5-point ranked ordinal scale administered by a phone survey up to 7 years after surgery.
Results
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.
Conclusions
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.
Endometriosis is a chronic inflammatory disease that drives pain, organ dysfunction, and infertility. How RRM-trained clinicians diagnose and treat it through excision surgery, cycle charting, and longitudinal care.
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