Diaphragmatic endometriosis was symptom-free in 17 of 24 women
Diaphragm endometriosis came with no symptoms in about 7 out of 10 women studied. This case series from two referral centers reviewed 24 women. All 7 women with symptoms had fewer symptoms afterward, and none had postoperative complications from treatment.
Key Findings
Of 24 women, 7 had shoulder, chest, epigastric or right upper quadrant pain suggesting diaphragm disease. The other 17 reported no symptoms directly related to it.
Lesions sat only on the right hemidiaphragm in 14 women, only on the left in 2, and on both sides in 8. Deep muscle infiltration occurred in 7, 4 of them symptomatic.
Six lesions in 7 patients lay directly over the left ventricle, and three lay next to the phrenic nerve.
All 7 symptomatic women had fewer symptoms after treatment, with follow-up of at least 12 months. None had complete relief, and symptoms returned in 2 women with deep lesions.
CO2 laser treated lesions in 20 women, and CO2 laser plus ultrasonic surgery in 1. Three women without symptoms went untreated. One later had chest pain the authors linked to it.
Interpretation
This retrospective case series reviewed charts of 24 women treated at two referral centers between April 1990 and November 1996. The design has no comparison group and cannot show cause. Diagnosis rested on how lesions looked at surgery, and biopsies of the diaphragm were not routine. The paper describes relief in words. All 24 women had endometriosis elsewhere. The authors write that the natural history is unknown and that treating silent lesions remains undetermined. One woman had sporadic premature ventricular contractions during ultrasonic treatment.
RRM Context
Restorative reproductive medicine treats endometriosis by excision. The authors vaporized superficial diaphragm lesions with laser and cut out deep lesions. The series compares neither method. Superficial lesions came back in 1 woman. The authors advise a full look at the whole abdomen at every laparoscopy, diaphragm included.
Our editorial summary of this paper, not the article's abstract.
Abstract
Objective
To review the clinical presentations of and management options for diaphragmatic endometriosis.
Design
Retrospective review.
Setting
Referral center.
Patients
Twenty-four women with endometriosis of the diaphragm.
Interventions
Surgical management.
Main Outcome Measures
Diagnostic accuracy and therapeutic feasibility of operative laparoscopy.
Results
Operative findings in 17 patients included 2-5 spots of endometriosis on the diaphragm measuring <1 cm. Seven women had numerous lesions scattered across the diaphragm. Lesions were bilateral in 8 patients, limited to the right hemidiaphragm in 14 patients, and limited to the left hemidiaphragm in 2 patients. In 7 patients, six endometriosis lesions were directly in the line of the left ventricle and three lesions were adjacent to the phrenic nerve. Endometriosis was infiltrating into the muscular layer of the diaphragm in 7 patients. The symptoms in all 7 symptomatic patients decreased significantly after treatment, with a minimum follow-up period of 12 months. No postoperative complications occurred.
Conclusions
The abdominal diaphragm can be involved with endometriosis and can be diagnosed and treated effectively with the use of videolaparoscopy.
Nezhat C et al., 2024·J Clin Med·Free full text on PubMed Central
Endometriosis, a systemic ailment, profoundly affects various aspects of life, often eluding detection for over a decade. This leads to enduring issues such as chronic pain, infertility, emotional strain, and potential organ dysfunction. The prolonged absence of diagnosis can contribute to unexplained obstetric challenges and fertility issues, necessitating costly and emotionally taxing treatments. While biopsy remains the gold standard for diagnosis, emerging noninvasive screening methods are gaining prominence. These tests can indicate endometriosis in cases of unexplained infertility, offering valuable insights to patients and physicians managing both obstetric and non-obstetric conditions. In a retrospective cross-sectional study involving 215 patients aged 25 to 45 with unexplained infertility, diagnostic laparoscopy was performed after unsuccessful reproductive technology attempts. Pathology results revealed tissue abnormalities in 98.6% of patients, with 90.7% showing endometriosis, confirmed by the presence of endometrial-like glands and stroma. The study underscores the potential role of endometriosis in unexplained infertility cases. Although the study acknowledges selection bias, a higher than previously reported prevalence suggests evaluating endometriosis in patients who have not responded to previous reproductive interventions may be justified. Early detection holds significance due to associations with ovarian cancer, prolonged fertility drug use, pregnancy complications, and elevated post-delivery stroke risk.
Rahmioglu N et al., 2023·Nat Genet·Free full text on PubMed Central
Endometriosis is a common condition associated with debilitating pelvic pain and infertility. A genome-wide association study meta-analysis, including 60,674 cases and 701,926 controls of European and East Asian descent, identified 42 genome-wide significant loci comprising 49 distinct association signals. Effect sizes were largest for stage 3/4 disease, driven by ovarian endometriosis. Identified signals explained up to 5.01% of disease variance and regulated expression or methylation of genes in endometrium and blood, many of which were associated with pain perception/maintenance (SRP14/BMF, GDAP1, MLLT10, BSN and NGF). We observed significant genetic correlations between endometriosis and 11 pain conditions, including migraine, back and multisite chronic pain (MCP), as well as inflammatory conditions, including asthma and osteoarthritis. Multitrait genetic analyses identified substantial sharing of variants associated with endometriosis and MCP/migraine. Targeted investigations of genetically regulated mechanisms shared between endometriosis and other pain conditions are needed to aid the development of new treatments and facilitate early symptomatic intervention.
Nezhat C et al., 2019·JSLS : Journal of the Society of Laparoendoscopic Surgeons·Free full text on PubMed Central
Endometriosis is characterized by the presence of endometrial-like glands and stroma outside the uterine cavity and is believed to affect 6%-10% of reproductive-age women. Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES). Computerized searches of MEDLINE and PubMed were conducted using the key words "thoracic endometriosis," "catamenial pneumothorax," "catamenial hemothorax," and "catamenial hemoptysis." References from identified sources were manually searched to allow for a thorough review. TES can produce incapacitating symptoms for some patients. Symptoms of TES are nonspecific, so a high degree of clinical suspicion is warranted. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected TES uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.
Dun EC et al., 2015·JSLS : Journal of the Society of Laparoendoscopic Surgeons·Free full text on PubMed Central
Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes. We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery. The mean age at the time of surgery was 17.2 (2.4) years (range, 10-21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1-132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1-12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain. Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.
To describe symptoms, surgical diagnosis and treatment, and long-term outcome of patients with symptomatic diaphragmatic endometriosis. Observational follow-up study. 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.
Endometriosis, an underdiagnosed and undertreated condition, affects 1 in 10 women and is associated with pain and infertility. Preoperative evaluation should include testing and management of other causes of pelvic pain. Ultrasonography can aid in surgical planning. Hormonal suppression improves symptoms, but should not be used to diagnose endometriosis, and is not shown to be effective in preventing disease recurrence nor in improving fertility. The goal of surgical management should be optimal removal or treatment of disease and should include measures for adhesion prevention. Rates of recurrence of endometriosis depend on the surgical completeness of removing the disease.
To present a case of recurrent catamenial pneumothorax and diaphragmatic endometriosis that was managed thoracoscopically. A review of the literature is also presented. A-28-year-old woman presented with bloody stools, chronic constipation, and chest pain. A review of systems was positive for monthly chest pain associated with her menses. A preoperative chest x-ray revealed a right pneumothorax. Colonoscopy revealed biopsy proven endometriosis of the sigmoid colon. A pelvic computed tomography scan revealed bilateral complex, cystic and solid adenexal lesions. A right thoracoscopy was performed. A lesion on the right hemidiaphragm was excised and confirmed to be endometriosis. A wedge section of lung tissue containing a bleb was resected and also contained endometriosis. Three months later, the patient underwent laparoscopic excision of her pelvic endometriosis, including a low anterior rectal resection. Five months later, she presented again with right-sided chest pain. A thoracoscopic right total pleurectomy was performed for recurrent pneumothorax. Pullmonary endometriosis may present as chest pain, shortness of breath, or hemoptysis associated with menstrual cycles. This case emphasizes the importance of a careful review of systems in patients with known endometriosis. Management now includes an endoscopic alternative and all of its known benefits.
To determine the long-term outcome after laparoscopic excision of endometriosis. This longitudinal unmatched study evaluated surgical outcome using follow-up questionnaires and evaluation of reoperations with results presented in life table format. Surgery was performed by a private practitioner at a referral center. All 359 patients undergoing laparoscopic excision of endometriosis between December 12, 1980, and March 31, 1990, were studied. Endometriosis, including deeply invasive disease, was completely excised laparoscopically using 3-mm scissors and graspers. Adjunctive medical therapy was not used. Extent of disease present at reoperation and quarterly rates of reoperation and recurrent/persistent disease are used as indicators of efficacy of surgery. Interval rates of reoperation and recurrence/persistence of disease and extent or invasiveness of disease when found at reoperation did not increase with the passage of time after surgery. The maximum cumulative rate of recurrent or persistent disease was 19%, achieved in the 5th postoperative year. Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.
Endometriosis › Surgical Treatment › Excision Surgery
Camran Nezhat
C Nezhat
PMID 9627291 9627291 DOI 10.1016/s0015-0282(98)00056-9 10.1016/s0015-0282(98)00056-9 Nezhat et al. 1998, Nezhat 1998
Cite this article
Nezhat, C., Seidman, D. S., Nezhat, F., & Nezhat, C. (1998). Laparoscopic surgical management of diaphragmatic endometriosis. Fertility and sterility, 69(6), 1048-1055. https://doi.org/10.1016/s0015-0282(98)00056-9
Nezhat C, Seidman DS, Nezhat F, Nezhat C. Laparoscopic surgical management of diaphragmatic endometriosis. Fertil Steril. 1998;69(6):1048-1055. doi:10.1016/s0015-0282(98)00056-9
Nezhat, C., et al. "Laparoscopic surgical management of diaphragmatic endometriosis." Fertility and sterility, vol. 69, no. 6, 1998, pp. 1048-1055.
