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Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center’s experience on 215 patients

A Correction to this article was published on 13 January 2021

This article has been updated

Abstract

Background

Diaphragmatic endometriosis (DE) is a rare and often misdiagnosed condition. Most of the times it is asymptomatic and due to the low accuracy of diagnostic tests, it is almost always detected during surgery for pelvic endometriosis. Its management is challenging and, until now, there are not guidelines about its treatment.

Methods

We describe a consecutive series of patients with DE managed by laparoscopy and videothoracoscopy (VATS) in our referral center in a period of 15 years. We developed a flow-chart classifying DE implants in foci, plaques and nodules and proposing an algorithm with the aim of standardizing the surgical approach.

Results

215 patients were treated for DE. Lesions were almost always localized on the right hemidiaphragm (91%), and the endometriotic implants were distributed as: foci in 133 (62%), plaques in 24 (11%) and nodules in 58 patients (27%), respectively. In all cases of isolated pleural involvement, concomitant diaphragmatic hernia or lesions of the thoracic side of the diaphragm VATS was performed, alone or combined with laparoscopy, resulting in a total of 26 procedures. Following the proposed algorithm, specific surgical techniques were identified as the better approaches for the different types of the lesion, such as Argon Beam Coagulation and diathermocoagulation for diaphragmatic foci, peritoneal stripping for plaques, and nodulectomy or full-thickness resection of diaphragm for nodules.

Conclusions

It is crucial to standardize the surgical approach of DE, according to the type of lesion, thus reducing the rate of under- or over-treatments and intra or postoperative complications. This kind of surgery should be performed in a Referral Center by a gynecologic surgeon with oncogynecologic expertise and skills, with the eventual support of a laparoscopic general surgeon, a specialized thoracic surgeon and a trained anesthesiologist.

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References

  1. Nezhat C, Lindheim SR, Backhus L, Vu M, Vang N, Nezhat A, Nezhat C (2019) Thoracic endometriosis syndrome: a review of diagnosis and management. J Soc Laparoendosc Surg 23(3):e2019.00029

    Article  Google Scholar 

  2. Veeraswamy A, Lewis M, Mann A, Kotikela S, Hajhosseini B, Nezhat C (2010) Extragenital endometriosis. Clin Obstet Gynecol 53:449–466

    Article  Google Scholar 

  3. Markham SM, Carpenter SE, Rock JA (1989) Extrapelvic endometriosis. Obstet Gynecol Clin North Am 16:193–219

    CAS  Article  Google Scholar 

  4. Joseph J, Sahn SA (1996) Thoracic endometriosis syndrome: new observations from an analysis of 110 cases. Am J Med 100:164–170

    CAS  Article  Google Scholar 

  5. Andres MP, Arcoverde FV, Souza CC, Fernandes LF, Abrao MS, Kho RM (2020) Extrapelvic endometriosis: a systematic review. J Minim Invasive Gynecol 27(2):373–389. https://doi.org/10.1016/j.jmig.2019.10.004

    Article  PubMed  Google Scholar 

  6. Drye JC (1948) Intraperitoneal pressure in the human. Surg Gynecol Obstet 87:472–475

    CAS  PubMed  Google Scholar 

  7. Foster DC, Stern JL, Buscema J, Rock A, Woodruff JD (1989) Pleural and pulmonary endometriosis. Obstet Gynecol 58:552–556

    Google Scholar 

  8. Alifano M, Trisolini R, Cancellieri A, Regnard JF (2006) Thoracic endometriosis: current knowledge. Ann Thorac Surg 81:761–769

    Article  Google Scholar 

  9. Fukuoka M, Kurihara M, Haga T, Ebana H, Kataoka H, Mizobuchi T, Tatsumi K (2015) Clinical characteristics of catamenial and non-catamenial thoracic endometriosis-related pneumothorax. Respirology 20(8):1272

    Article  Google Scholar 

  10. Kumakiri J, Kumakiri Y, Miyamoto H, Kikuchi I, Arakawa A, Kitade M, Takeda S (2010) Gynecologic evaluation of catamenial pneumothorax associated with endometriosis. J Minim Invasive Gynecol 17(5):593–599

    Article  Google Scholar 

  11. Meyers MA (1970) The spread and localization of acute intraperitoneal effusions. Radiology 95:547–554

    CAS  Article  Google Scholar 

  12. Meyers MA (1973) Distribution of intra-abdominal malignant seeding: dependency on dynamics of flow of ascitic fluid. Am J Roentgenol Radium Ther Nucl Med 119:198–206

    CAS  Article  Google Scholar 

  13. American Society for Reproductive Medicine (1997) Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril 67:817–821

    Article  Google Scholar 

  14. Nirgianakis K, Lanz S, Imboden S, Worni M, Mueller MD (2018) Coagulation-induced diaphragm fenestrations after laparoscopic excision of diaphragmatic endometriosis. NirgJ Minim Invasive Gynecol 25(5):771–772. https://doi.org/10.1016/j.jmig.2017.10.028

    Article  Google Scholar 

  15. Viti A, Bertoglio P, Roviglione G, Clarizia R, Ruffo G, Ceccaroni M, Terzi AC (2019) Endometriosis involving the diaphragm: a patient-tailored minimally invasive surgical treatment. World J Surg 44:1099

    Article  Google Scholar 

  16. Ceccaroni M, Clarizia R, Placci A (2010) Pericardial, pleural, and diaphragmatic endometriosis. J Thorac Cardiovasc Surg 140(5):1189–1190

    Article  Google Scholar 

  17. Scioscia M, Bruni F, Ceccaroni M, Steinkasserer M, Stepniewska A, Minelli L (2011) Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy. Acta Obstet Gynecol Scand 90(2):136–139

    Article  Google Scholar 

  18. Ceccaroni M, Roviglione G, Giampaolino P, Clarizia R, Bruni F, Ruffo G, Patrelli TS, De Placido G, Minelli L (2013) Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review. Surg Endosc 27(2):625–632

    Article  Google Scholar 

  19. Fischerova D (2011) Ultrasound scanning of the pelvis and abdomen for staging of gynecological tumors: a review. Ultrasound Obstet Gynecol 38(3):246–266. https://doi.org/10.1002/uog.10054

    CAS  Article  PubMed  Google Scholar 

  20. Indrielle-Kelly T, Frühauf F, Burgetová A, Fanta M, Fischerová D (2019) Diagnosis of endometriosis 3rd part – Ultrasound diagnosis of deep endometriosis. Ceska Gynekol 84(4):269–275

    CAS  PubMed  Google Scholar 

  21. Marchiori E, Zanetti G, Rodrigues RS, Souza LS, Souza Junior AS, Francisco FA, Hochhegger B (2012) Pleural endometriosis: findings on magnetic resonance imaging. J Bras Pneum- Mol 38:797–802

    Article  Google Scholar 

  22. Rousset P, Gregory J, Rousset-Jablonski C, Hugon-Rodin J, Regnard JF, Chapron C, Coste J, Golfier F, Revel MP (2016) MR diagnosis of diaphragmatic endometriosis. Eur Radiol 26:3968–3977

    Article  Google Scholar 

  23. Cosma S, Salgarello M, Ceccaroni M, Gorgoni G, Riboni F, La Paglia E, Danese S, Benedetto C (2016) Accuracy of a new diagnostic tool in deep infiltrating endometriosis: Positron emission tomography–computed tomography with 16α-[18F]fluoro-17β-estradiol. J Obstet Gynaecol Res 42:1724

    CAS  Article  Google Scholar 

  24. Vercellini P, Abbiati A, Vigano P, Somigliana ED, Daguati R, Meroni F, Crosignani PG (2007) Asymmetry in distribution of diaphragmatic endometriotic lesions: evidence in favour of the menstrual reflux theory. Hum Reprod 22:2359–2367

    CAS  Article  Google Scholar 

  25. Ishimura T, Masuzaki H (1991) Peritoneal endometriosis: endometrial tissue implantation as its primary etiologic mechanism. Am J Obstet Gynecol 165:214–218

    Article  Google Scholar 

  26. Halkia E, Efstathiou E, Spiliotis J, Romanidis K, Salmas M (2014) Management of diaphragmatic peritoneal carcinomatosis: surgical anatomy guidelines and results. J BUON 19(1):29–33

    PubMed  Google Scholar 

  27. Nezhat C, Main J, Paka C, Nezhat A, Beygui RE (2014) Multidisciplinary treatment for thoracic and abdominopelvic endometriosis. JSLS 18(3):e2014.00312. https://doi.org/10.4293/JSLS.2014.00312

    Article  PubMed  PubMed Central  Google Scholar 

  28. Chiantera V, Dessole M, Petrillo M, Lucidi A, Frangini S, Legge F, Scambia G, Mechsner S (2016) Laparoscopic en bloc right diaphragmatic peritonectomy for diaphragmatic endometriosis according to the sugarbaker technique. J Minim Invasive Gynecol 23(2):198–205. https://doi.org/10.1016/j.jmig.2015.09.020

    Article  PubMed  Google Scholar 

  29. Larraín D, Suárez F, Braun H, Chapochnick J, Diaz L, Rojas I (2018) Thoracic and diaphragmatic endometriosis: Single-institution experience using novel, broadened diagnostic criteria. J Turk Ger Gynecol Assoc 19(3):116–121

    Article  Google Scholar 

  30. Roman H, Darwish B, Provost D, Baste JM (2016) Laparoscopic management of diaphragmatic endometriosis by three different approaches. Fertil Steril 106(2):e1

    Article  Google Scholar 

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Correspondence to Giovanni Roviglione.

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Marcello Ceccaroni, Giovanni Roviglione, Antonino Farulla, Pietro Bertoglio, Roberto Clarizia, Andrea Viti, Daniele Mautone, Matteo Ceccarello, Anna Stepniewska, and Alberto Claudio Terzi declare that they have no conflict of interest.

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This article was updated to correct the author listing, where given names and surnames were reversed.

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Ceccaroni, M., Roviglione, G., Farulla, A. et al. Minimally invasive treatment of diaphragmatic endometriosis: a 15-year single referral center’s experience on 215 patients. Surg Endosc 35, 6807–6817 (2021). https://doi.org/10.1007/s00464-020-08186-z

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  • DOI: https://doi.org/10.1007/s00464-020-08186-z

Keywords

  • Endometriosis
  • Laparoscopy
  • Diaphragm
  • Minimally invasive surgery
  • Thoracoscopy