Mise au point sur la prise en charge chirurgicale de l'endométriose thoracique et diaphragmatique à partir d'une étude rétrospective multicentrique française

Introduction: Diaphragmatic and thoracic endometriosis (DTE) is rare but remains a classical and poorly known disease. Specialists who take over this pathology are gynecologist, thoracic or digestive surgeons. Thoracic and abdominal approaches are both used to destroy or remove diaphragmatic lesions. Surgical managements are multiples. Up to now, no guidelines are available for surgeons. Material and methods: Retrospective study from January 2010 to November 2017 in 8 units of 5 French institutions. 50 women operated for DTE were included and contacted by phone. The aim of this study was to review the clinical presentations, management options for DTE and analyze the outcomes after surgery. Results: Mean age was 34,3 y.o. (Range: 24-46). Women had a history of infertility in 46% of the cases, 50% had a preoperative diagnosis of pelvic endometriosis, all of them had deep endometriosis and 72% of these cases were classified as severe endometriosis. For 22% of the patients, the DTE and pelvic endometriosis were diagnosed at the same time. DTE was discovered on symptoms for 76% of the case after chronic or catamenial chest pain (36%), pneumothorax (38%) or hemo-pneumothorax (2%). Only 3 patients of the abdominal group were totally asymptomatic (=6%). Median time from onset of symptoms to diagnosis of DTE was 47 months (range 0-212): 33,5 months in the thoracic approach group (0-212) vs 50,5 months in the abdominal approach group (0-90) (p>0,05*). Diagnosis of DTE was performed the day of the surgery for 58% of the patients (85% of the patients in the thoracic group vs 29% of the patients in the abdominal group, p<0,05) . When it was done previously, median time from diagnosis to surgery was 6 months (range 1-45): 11,5 months (5-33) in the thoracic approach group vs 5 (1-45) months in the abdominal approach group (p>0,05). DTE surgery was associated with pelvic endometriosis removal in 44% of the cases, all patients belonged to the abdominal group, no combined surgeries were performed. The approach was thoracic for 52% of the patients (video assisted thoracoscopic surgery n=19, thoracotomy n=7), and abdominal for 48% (laparoscopy : n=19, laparotomy n=5). DTE lesions were right-sided in 90%, left-sided in 2% and bilateral in 8% of the cases. DTE lesions presented as diaphragmatic nodules (n=42), or pleuro-pulmonary nodules (n=5) or diaphragmatic perforation (n=22). Nodules were excised in 76% of the cases and destructed for 26% of the patients. In case of diaphragmatic reconstruction, a simple suture was performed in 84% of the cases, and 16% needed a prosthetic mesh repair. Pleural symphysis was always performed for patients with thoracic approach. Full completeness of reductive surgery was achieved for 90% of the patients. In case of abdominal approach, a chest drain was placed in 38% of the cases (n=9). Three patients (6 %) had severe 30-days DTE post-operative complications (Dindo-Clavien 3-4): one major haemothorax and 2 recurrent post-operatives pneumothorax (requiring local chest drainage (n=1) or additional surgery by thoracotomy (n=1)). Median follow-up was 20 months long. Ten patients (20%) experienced a recurrence of the DTE relative symptoms. Among them, only one patient needed additional surgery for recurrent pneumothorax despite a complete debulking at the first surgery. Another patient presented a diaphragmatic hernia 12 months after the first surgery without recurrence and needed a mesh repair. A pelvic endometriosis was found later for 10% of these women. In the thoracic group, 3 women (12%) did not have any gynecologic follow-up and pelvic exploration after DTE surgery. Conclusion : This is the largest cohort of patients operated for DTE. Postoperative morbidity and recurrence of symptoms are significant. Surgical procedures and postoperative follow-ups are not standardized. Guidelines are needed.