Two Cases of Diaphragmatic Endometriosis: One Superficial and One Full-Thickness Resection скачать в хорошем качестве

Two Cases of Diaphragmatic Endometriosis: One Superficial and One Full-Thickness Resection

Two cases of diaphragmatic endometriosis are presented to illustrate diagnosis and management of this rare condition within thoracic endometriosis syndrome. Diaphragmatic endometriosis involves endometrial tissue on the diaphragm, pleural space, or lung parenchyma. Symptoms may include catamenial pain, pneumothorax, hemothorax, pleural effusion, hemoptysis, or pulmonary nodules. Mean age of onset is about 35 years, later than pelvic endometriosis. Most patients experience pelvic pain first, and 50–84 % also have pelvic disease. History is critical for diagnosis, which is ultimately confirmed by laparoscopy. Imaging can be negative, and disease may be hidden by the liver, delaying recognition even at surgery. Medical therapy is first-line treatment, mirroring pelvic endometriosis protocols. When surgery is required, a multidisciplinary team—radiology, anesthesia, thoracic surgery, and gynecology—offers the safest approach. Video-assisted thoracoscopic surgery addresses thoracic lesions, while laparoscopy is used for diaphragmatic disease. The first case is a 35-year-old gravida 2, para 2 with catamenial right upper-quadrant pain. CT imaging was unremarkable. She had prior surgery for congenital intestinal malrotation and pathology-proven endometriosis, central sensitization, and failure of multiple medical therapies. Suspected diaphragmatic endometriosis led to total laparoscopic hysterectomy, excision of pelvic endometriosis, and planned diaphragmatic resection with thoracic surgery consultation. Initial abdominal survey was negative until the liver was retracted. Adhesions between liver and diaphragm were lysed with monopolar hook cautery. The diaphragm was scored circumferentially, traction applied, and striated muscle exposed. The lesion proved deeply infiltrating and required full-thickness diaphragmatic resection, creating a small window into the pleural cavity where the lower right lung lobe was visible. No pleural lesions were seen. The diaphragm was closed with three interrupted horizontal mattress sutures of 0 Ethibond. Postoperative recovery was uneventful aside from a small apical pneumothorax managed conservatively without a chest tube. Pathology of the diaphragmatic nodules was negative for endometriosis. According to ESHRE guidelines, negative histology does not exclude disease. A review of diaphragmatic endometriosis using direct surgical inspection reported many cases with negative standard histology but positive estrogen and progesterone receptor staining on immunohistochemistry. One study of 55 thoracic cases found only a single histology-positive sample, with 67 % positive only on receptor testing. The patient was followed at six and eleven weeks, continued to experience right upper-quadrant pain, and was referred back to thoracic surgery while starting hormonal therapy. The second case is a 44-year-old with long-standing pelvic endometriosis and chronic pain. She previously underwent laparoscopic myomectomy with removal of superficial endometriosis and was taking cyclic oral contraceptives. Persistent right upper-quadrant pain was unresponsive to medical therapy. Imaging of the chest was not performed. Laparoscopy revealed a nodule in the right hemidiaphragm. The peritoneum was scored circumferentially with monopolar hook cautery, releasing chocolate-colored fluid. Traction and cautery allowed careful undermining, and a ligature device bluntly separated the nodule from diaphragmatic muscle while preserving the pleural cavity. The lesion was excised completely without entering the pleura. Histology confirmed endometriosis. Recovery was uncomplicated, and she was discharged on postoperative day 1 with complete resolution of pain at six-week follow-up. These cases highlight the diagnostic difficulty of diaphragmatic endometriosis. Imaging may be negative and lesions concealed by the liver. Techniques such as using a 30-degree laparoscope, reverse Trendelenburg positioning, and liver retraction improve visualization. Because lesions can require full-thickness resection and sometimes pleural entry, collaboration with thoracic surgery is essential. Even when histology is negative, clinical suspicion supported by intraoperative findings and immunohistochemistry should guide management. Early recognition, multidisciplinary planning, and meticulous surgical technique remain key to successful outcomes.