Diaphragma central tendon and catamenial pneumothorax

A case experience explaining surgical management of diaphragmatic endometriosis.

Key Points

Importance:

• Optimal surgical techniques for diaphragmatic endometriosis have not yet been established.

Highlights:

• The pathologic study of this case revealed that the endometrial tissue on the central tendon of the diaphragm is responsible for the development of catamanial pneumothorax.

What's done here:

• A 25-year-old, sex-experienced woman was diagnosed with endometriosis and referred to the tertiary hospital in Kishiwada, Japan.
• Twenty-one months ago, she had a pelvic endometriosis surgery in another medical center, and the immunostaining of the lesions showed strongly positive estrogen receptors.
• Her symptoms recovered after this surgery until catamenial pneumothorax occurred. 
• This paper explained the authors surgical approach and the postoperative findings of this catamenial pneumothorax case.

Key Results:

• Radiological and CT findings indicated air leakage in her right thorax and a mild lung collapse.
• The thoracoscopic examination showed multiple brownish diaphragmatic lesions, especially in the central tendon.
• After complete resection of all diaphragmatic lesions, pathological findings were diaphragmatic defects only in the central tendon site while other diaphragmatic tissues remained intact.
• The patient was discharged on the fourth day of the operation as cured and followed up for 21 months. During that period, she got another exacerbated operation from the pelvic endometriosis without any repeated catamenial pneumothorax.

Lay Summary

Endometriosis typically involves ectopic endometrial tissue in pelvic organs, such as the bladder, ovaries, and uterine ligaments, leading to symptoms like dysmenorrhea, dyspareunia, and dyschezia. A rare form occurs in the diaphragm, causing catamenial pneumothorax. Management often includes hormone therapy or ovarian suppression, with surgery beneficial, especially for women desiring pregnancy.

Inoue et al., from Kishiwada Tokushukai Hospital, Japan, reported the management of a case of a young unmarried woman with catamenial pneumothorax (a condition where lung collapse is associated with the menstruation), highlighting their surgical approach to remove endometriotic lesions from the diaphragmatic central tendon. Chest radiography revealed mild lung collapse with a history of shortness of breath during menstruation. A CT scan, performed after the recurrence of dyspnea, identified air leakage above the diaphragm in the right thorax. 

No cystic lesions on the pleura were observed during thoracoscopy, but multiple brownish lesions were found on the diaphragm and central tendon. All diaphragmatic defects were completely excised, and a polyglycolic sheet was extensively applied to the lesions. Pathological findings confirmed endometriosis on the diaphragm without any defects, while defects were present only in the central tendon of the diaphragm.

The authors emphasized that effective management of diaphragmatic central tendon defects is critical in the surgical treatment of catamenial pneumothorax. This article is recently published in Cureus.

Research Source: https://pubmed.ncbi.nlm.nih.gov/39974247/