{"paper_id":"7c3eab44-3c26-4192-930d-aa4bf9d36158","body_text":"Case Report\nVolume 13 Issue 5 - January 2019\nDOI: 10.19080/JGWH.2019.13.555873\nJ Gynecol Women’s Health\nCopyright © All rights are reserved by Aleksandr D Obornev\nJ Gynecol Women’s Health 13(5): JGWH.MS.ID.555873 (2019) 001\nJournal of\nGynecology and Women’s Health\nISSN 2474-7602\nEndometriosis-Associated Pneumothorax with \nHepatic Microherniations\nVadim G Pischik1,2, Aleksandr D Obornev1* and Olga S Maslak2\n1Clinical Hospital №122 named after LG Sokolov, Russia\n2Saint-Petersburg State University, Russia\nSubmission: January 09, 2019 ; Published: January 18, 2019\n*Corresponding author: Aleksandr Obornev, Clinical Hospital №122 named after LG Sokolov, Russia\nIntroduction\nThoracic endometriosis became an important cause of \nspontaneous pneumothorax in women in the last decades. This \ndisease is thought to have some special features, such as right-\nsided localization, frequent recurrences, difficulties in early \ndiagnosis and rather challenging surgical tactics to prevent \nrecurrence. Trans diaphragmatic air passage theory is one of the \nmost strong theories, describing the pathogenesis of this type of \npneumothorax. Thus, several studies described multiple nodules \non the diaphragmatic dome to be special signs of diaphragmatic \nendometriosis [1,2].\nWe present a case of multiple liver microherniations due \nto endometriotic diaphragmatic defects in a woman with right-\nsided pneumothorax and bilateral Fallopian tube resection.\nCase Report\nA 33-yr old female patient was referred to our hospital with \nmoderate right-sided chest pain during previous 3 days. She was \nin the second half of her menstrual cycle. On CT-scan we observed \na right-sided moderate pneumothorax with most amount of air \nover the right hemidiaphragm. On the diaphragmatic dome some \ntissue nodules were observed (Figure 1).\n \nThe patient revealed similar complaints during menstruation \nfor several previous months. We suspected endometriosis-\nassociated pneumothorax. However, the patient underwent left-\nsided ovarioectomy with bilateral fallopian tube resection due to \npelvic endometriosis in 2010. She experienced two unsuccessful \nattempts of extracorporeal fertilization in 2015,2016.\nOn the next day she underwent VATS. We found some \nadhesions between the lung and the chest wall, evidence of \nprevious pneumothoraces. While examining the diaphragmatic \ndome, strong adhesions with lung basal surface and \ndiaphragmatic perforations were noted (Figure 2).\nThere was no sign of macroscopic endometrial ectopies, \nbut soft-tissue nodules, seen on CT were presented with liver \ntissue, protruding into the pleural cavity through the defects \nin the diaphragm (Figure 3). We meticulously dissected the \nperforated part of the tendinous dome with all defects. After \nremoving of the dissected part, we revealed severely deformed \nsurface of the liver (Figure 4). After that, the diaphragm was \nclosed with separate sutures (Figure 5). We performed full costal \npleurectomy to prevent recurrences (Figure 6).\nAbstract \nWe present a case of multiple liver microherniations due to endometriotic diaphragmatic defects in a woman with right-sided \npneumothorax and bilateral Fallopian tube resection. A 33-yr old female patient was referred with moderate right-sided chest pain during \nprevious 3 days. On CT-scan we observed a right-sided moderate pneumothorax. On the diaphragmatic dome some tissue nodules were \nobserved. During VATS we observed liver tissue, protruding into the pleural cavity through the defects in the diaphragm. Resection of the \ntendinous portion was performed with separate suture closure of the diaphragm, added by costal pleurectomy. The patient was dispatched \nto the gynecologist for further treatment. After prescription of analogues of GNRH no sign of recurrence was seen. In our case no evidence \nof pulmonary abnormalities was seen, thus, excluding other ways of air passage to the pleural cavity. The only abnormal place was the \ndiaphragmatic dome. Surprisingly, the patient underwent bilateral tube resection in 2010. CT-scan findings, which were firstly proposed to be \nof endometriotic origin, revealed during VATS as liver microherniatons.\nKeywords: Catamenial pneumothorax; VATS; Thoracic endometriosis; Pleurectomy; Porous diaphragm\nAbbreviatations:  VATS: Video-Assisted Thoracic Surgery; GNRH: Gonadotropine-Releasing Hormone\n\n\nHow to cite this article: Vadim G P, Aleksandr D O, Olga S M. Endometriosis-Associated Pneumothorax with Hepatic Microherniations. J Gynecol \nWomen’s Health. 2019: 13(5): 555873. DOI: 10.19080/JGWH.2019.13.555873.002\nJournal of Gynecology and Women’s Health\nFigure 1: Diaphragmatic soft-tissue lesions and 3D-reconstruction.\nFigure 2: Adhesions between tendinous portion of the right hemidiaphragm with perforations and basal surface of the lung.\nPost operational period was uneventful. Pleural drain was \nremoved on the third day. Patient was dismissed on the fourth \nday. Estrogen receptors were found on immunostaining, thus \nconfirming the diagnosis of thoracic endometriosis. The patient \nwas dispatched to the gynecologist for further treatment. 18 days \nafter the operation there was a recurrence of small right-sided \npneumothorax, that resolved spontaneously. After prescription \nof analogues of GNRH no sign of recurrence was seen. \n\n003\nJournal of Gynecology and Women’s Health How to cite this article: Vadim G P, Aleksandr D O, Olga S M. Endometriosis-Associated Pneumothorax with Hepatic Microherniations. J Gynecol \nWomen’s Health. 2019: 13(5): 555873. DOI: 10.19080/JGWH.2019.13.555873.\nFigure 3: Liver tissue protruding through the diaphragmatic defect\nFigure 4: Deformed liver surface.\nFigure 5: Repaired defect of the tendinous portion of the \ndiaphragm.\nFigure 6: Full costal pleurectomy.\nDiscussion\nAccording to recently published data, EAP is a considerable \ncause of secondary spontaneous pneumothorax in women. \nIn all population of women with spontaneous pneumothorax \nit can comprise about 15% [3,4]. The lack of specific clinical \nsymptoms and necessity of careful visualisation of pleural cavity \nmakes early diagnosis difficult [1,5,6]. The leading role in its \npathogenesis, seems to belong to trans diaphragmatic passage of \nair to the pleural cavity. However, some cases show parenchymal \nendometriotic ectopies.\nIn our case no evidence of pulmonary abnormalities was \nseen, thus, excluding other ways of air passage to the pleural \ncavity. The only abnormal place was the diaphragmatic dome. \nSurprisingly, the patient underwent bilateral tube resection in \n2010. However, previous unsuccessful attempts of extracorporeal \nfertilization made us propose endometriosis-associated etiology \nof this pneumothorax. \nIt seems that there was some kind of tube recanalization \nduring those 7 years between two surgical events. \nCT-scan findings, which were firstly proposed to be \nof endometriotic origin, revealed during VATS as liver \nmicroherniatons. The amount of air and its localization over \nthe diaphragm is common for endometriosis-associated \npneumothorax. MRI of the diaphragm, which is considered to be \nmore specific in diagnosing endometriotic tissue than CT , was to \nour mind redundant, thus VATS can solve all the diagnostic and \nsurgical problems.\nSurgical treatment was performed according to most \npopular strategy nowadays [4,7,8]: excluding of air passage via \ndiaphragmatic defects and pleurectomy to prevent recurrences \nwith further conservative treatment under supervision of the \ngynecologist. Thereby, thoracic endometriosis can be the only \nsite of endometriosis, leading to “occult” infertility, undiagnosed \nin the absence of spontaneous pneomothoraces.\nReferences\n1. Visouli AN, Darwiche K, Mpakas A, Zarogoulidis P , Papagiannis A, et al. \n(2012) Catamenial pneumothorax: a rare entity? Report of 5 casesand \nreview of the literature. J Thorac Dis 4(suppl 1): 17-31.\n2. Rousset P , Rousset-Jablonski C, Alifano M, Mansuet-Lupo A, Buy JN, et \nal. (2014) Thoracic endometriosis syndrome: CT and MRI features. Clin \nRadiol 69(3): 323-330. \n3. Olive D, Pritts EA (2001) Treatment of Endometriosis. The New En -\ngland Journal of Medicine 345: 266-275.\n4. Ciriaco P , Negri G, Libretti L, Carretta A, Melloni G, et al. (2009) Surgical \ntreatment of catamenial pneumothorax: a single centre experience. In-\nteract Cardiovasc Thorac Surg 8(3): 349-352.\n5. Athwal P , Patel K, Hassani C, Bahadori S, Nardi P , et al. (2013) A case of \nmultisystem endometriosis. J Radiol Case Rep  7(10): 1-6.\n6. Attaran S, Bille A, Karenovics W, Lang-Lazdunski L (2013) Video tho -\nracoscopic repair of diaphragm and pleurectomy/abrasion in patients \nwith catamenial pneumothorax. A 9-year experience. Chest 143(4): \n1066-1069.\n\nHow to cite this article: Vadim G P, Aleksandr D O, Olga S M. Endometriosis-Associated Pneumothorax with Hepatic Microherniations. J Gynecol \nWomen’s Health. 2019: 13(5): 555873. DOI: 10.19080/JGWH.2019.13.555873.004\nJournal of Gynecology and Women’s Health\n7. Alifano M, Jablonski C, Kadiri H, Falcoz P , Gompel A, et al. (2007) Cata-\nmenial and Noncatamenial, Endometriosis-related or Nonendometrio-\nsis-related Pneumothorax Referred for Surgery. Am J Respir Crit Care \nMed 176(10): 1048-1053.\n8. Bobbio A, Trisolini R, Damotte D, Alifano M (2011) Thoracic endome -\ntriosis and catamenial pneumothorax. Eur Respir Mon 54: 265-281.\nSefrioui O, Madkour A, Aboulmaouahib S, Louanjli KIN (2018) Women \nwith extreme low AMH values could have in vitro fertilization success. \nGynecol Endocrinol 16:1-4.\nYour next submission with Juniper Publishers    \n      will reach you the below assets\n• Quality Editorial service\n• Swift Peer Review\n• Reprints availability\n• E-prints Service\n• Manuscript Podcast for convenient understanding\n• Global attainment for your research\n• Manuscript accessibility in different formats \n         ( Pdf, E-pub, Full Text, Audio) \n• Unceasing customer service\n                   Track the below URL for one-step submission \n            https://juniperpublishers.com/online-submission.php\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nDOI: 10.19080/JGWH.2019.13.555873","source_license":"CC0","license_restricted":false}