Diagnosis and management of treatment in diaphragmatic endometriosis.

Surgical radicality should be tailored based on intraoperative deep endometriosis characteristics.

Key Points

Importance:

• Diaphragmatic endometriosis is a rare condition with poor knowledge concerning diagnosis, surgical indications, and techniques.

Highlights:

• Only highly skilled surgeons with extensive onco-gynecologic expertise should perform the diaphragmatic endometriosis surgery.
• Minimally invasive surgery and thoracic approach are the gold standard techniques for this type of endometriosis.

What's done here:

• This paper summarizes the recent evidence-based data about the proper management and available treatment options for diaphragmatic endometriosis.
• The authors also mentioned their classification according to lesions and proposed an algorithm to standardize the surgical methods based on this classification of diaphragmatic endometriosis.

Basic Outlines:

• Worsening symptoms during menstrual cycles and the right-dominant distribution of diaphragmatic endometriosis may help the clinical diagnosis.
• Diaphragmatic endometriosis usually develops in severe deep endometriosis cases. The history of recurrent spontaneous pneumothorax is another factor facilitating the diagnosis.
• Several imaging techniques, such as ultrasonography, chest X-ray, CT, and MRI, are used to diagnose lesions on the diaphragm.
• Surgical excision is considered the treatment of choice in cases of diaphragmatic endometriosis, even though it is diagnosed during routine laparoscopy.
• Hormonal treatment is under debate due to the high recovery failure. However, it is strongly recommended after the ablation/resection of the lesions to prevent the risk of relapse.
• The authors' group who penned this article have a diaphragmatic endometriosis classification based on the lesions named foci, nodules, and plagues.
• According to their classification, an algorithm is suggested that aims to standardize the surgical treatment.
• Describing the surgery for superficial, partial-thickness, and full-thickness lesions and explaining the surgery-related complications are the further details of this paper.
• The authors indicate that minimally invasive surgery is the gold standard and compare the thoracic and abdominal approaches for the main therapeutic management of diaphragmatic endometriosis.

Lay Summary

Diaphragmatic endometriosis is a rare extra-pelvic type of deep endometriosis with a prevalence of 0,19% to 4,75. In symptomatic women, the symptoms are characterized by non-specific chest pain, shoulder pain, right upper quadrant abdominal pain, and pneumothorax, whereas 75% of patients have a silent course that makes the diagnosis difficult. The clockwise peritoneal fluid current from the pelvis to the falciform and phrenic-colic ligaments explains why endometriotic lesions are seen 90% asymmetrically on the right side of the diaphragm. A previous spontaneous pneumothorax is strongly indicative of diaphragmatic endometriosis. These patients are managed mainly by thoracic surgeons, which can cause inefficient and inappropriate treatment of the disease. 

Ceccaroni et al. from the Department of Obstet.Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery of Sacro Cuore-Don Calabria Hospital, Verona, Italy, penned this paper to explain the difficulties of diagnosing, classifying, and surgically approaching diaphragmatic endometriosis. The paper was recently published in Best Practice & Research Clinical Obstet & Gynaecology.

Although some authors may prefer to avoid surgical treatment to eliminate life-threatening surgical complications, this author's group believes in radical surgical manipulation to complete eradication of the disease. The best candidates for the surgery are women who are symptomatic patients and unresponsive to medical therapy, even though a large percentage of them are asymptomatic and are diagnosed incidentally during surgery. Several surgical techniques have been used to treat diaphragmatic endometriosis. Endometrial lesions should be excisioned according to their characteristics to minimize surgical complications. With this belief, the authors recommended to divide the lesions into three groups and to plan the surgical approach accordingly.

Small superficial lesions under 1 cm are named "foci" and treated by simple bipolar cotarization. If the implant is greater than 1 cm, they prefer peritoneal stripping, including incising the lesion with surrounding healthy tissue without an underlying muscular layer. In cases of partial diaphragm involvement, they call the lesions "nodules" and propose performing a nodulectomy, taking care not to enter the thoracic cavity. The most severe form and the third type of endometriotic lesion is called "plague" and is healed by full-thickness diaphragmatic incisions. The authors recommended entering both the thoracic and abdominal cavities while performing this procedure to ensure a complete CO2 pneumothorax evacuation.

The authors' conclusion is "surgical radicality should be tailored based on intraoperative deep endometriosis lesions according to standardize the operative management of the disease."

Research Source: https://pubmed.ncbi.nlm.nih.gov/38710608/