Endometriosis
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Thoracic Endometriosis and Video Assisted Thoracoscopy

Thoracic Endometriosis and Video Assisted Thoracoscopy
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Video Description

This video discusses the various levels and techniques of ultrasound in the setting of endometriosis and highlights specifics markers of endometriosis to investigate for.

Presented By

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Dr. Neha Sarna
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Dr. Negar Ahmadi
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Dr. Jamie Kroft

Affiliations

University of Toronto

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What is Thoracic Endometriosis and Video Assisted Thoracoscopy?

Thoracic Endometriosis is a rare form of endometriosis where endometrial tissue, which typically lines the uterus, is found in the thoracic cavity, particularly on the diaphragm, lungs, and pleura. Here’s a brief overview:

  • Symptoms: Includes chest pain, shortness of breath, shoulder pain, and pneumothorax (collapsed lung), often correlating with the menstrual cycle.
  • Diagnosis: Typically involves imaging studies such as CT scans, MRI, and sometimes biopsy to confirm the presence of endometrial tissue in the thoracic cavity.

Video Assisted Thoracoscopy (VATS) is a minimally invasive surgical technique used to diagnose and treat conditions within the chest, including thoracic endometriosis. Here’s a brief overview:

  • Procedure: Performed under general anesthesia, small incisions are made in the chest through which a thoracoscope (a small camera) and surgical instruments are inserted. This allows for visual inspection and treatment of the thoracic cavity.
  • Applications: Used to remove endometrial implants, biopsy suspicious lesions, and manage complications such as pneumothorax.
  • Benefits: Includes reduced postoperative pain, shorter hospital stay, faster recovery compared to traditional open surgery, and the ability to diagnose and treat conditions simultaneously.

Together, understanding thoracic endometriosis and utilizing VATS can significantly improve the diagnosis, treatment, and management of this rare condition.

What are the Risks of Thoracic Endometriosis and Video Assisted Thoracoscopy?

Risks of Thoracic Endometriosis:

  1. Delayed Diagnosis: Due to its rarity and non-specific symptoms, thoracic endometriosis can be misdiagnosed, leading to delays in appropriate treatment.
  2. Recurrent Pneumothorax: Endometrial implants in the lungs or pleura can cause recurrent pneumothorax (collapsed lung), which can be life-threatening if not managed promptly.
  3. Chronic Pain: Persistent chest or shoulder pain due to endometrial lesions can significantly affect quality of life.
  4. Respiratory Complications: Severe cases can lead to respiratory distress or complications from associated pleural effusion (fluid accumulation).

Risks of Video Assisted Thoracoscopy (VATS):

  1. Infection: As with any surgical procedure, there is a risk of infection at the incision sites or within the thoracic cavity.
  2. Bleeding: Potential for intraoperative or postoperative bleeding, especially from blood vessels in the thoracic cavity.
  3. Injury to Surrounding Organs: Accidental injury to nearby structures such as the lungs, heart, or major blood vessels can occur during the procedure.
  4. Anesthesia Risks: Complications related to general anesthesia, including allergic reactions or respiratory issues, may arise.
  5. Pain and Discomfort: Postoperative pain and discomfort are common, though usually less severe than with traditional open surgery.
  6. Incomplete Removal of Lesions: There is a possibility that not all endometrial lesions are detected or removed, which could result in persistent or recurrent symptoms.
  7. Pneumothorax: Though VATS is used to treat pneumothorax, the procedure itself can occasionally cause a pneumothorax.

Despite these risks, VATS is generally considered a safe and effective method for diagnosing and treating thoracic endometriosis, offering the advantages of a minimally invasive approach.

Video Transcript: Thoracic Endometriosis and Video Assisted Thoracoscopy

Thoracic endometriosis and video assisted thoracoscopy. Endometriosis is defined as the presence of endometrial glands and stroma outside of the normal location. It is most commonly localised to the pelvis. However, extra-pelvic locations do occur, with thoracic endometriosis being the most common location.

Thoracic endometriosis includes the findings of endometriosis in any of the following components of the thoracic cavity, including the pleura, the parenchyma, the diaphragm, the bronchus. Risk factors include a history of pelvic endometriosis or previous uterine surgery.

Symptoms for these patients start any time from just prior to the start of menstruation, and approximately three days into their cycle. They can present with either isolated or catamenial pneumothoraces, haemothoraces, haemoptysis, and pulmonary nodules. Cyclic pain, however, is the most common presenting symptom.

Treatment for patients with thoracic endometriosis usually entails a management of the immediate presenting concern, followed by consideration to prevent recurrence. Recurrence can be managed through either medical or surgical modalities. The specifics of medical management are beyond the scope of the video today. According to the most recent ESHRE endometriosis statement released in 2022, surgical management includes the use of video assisted thoracoscopy, which is considered the preferred surgical technique for managing thoracic endometriosis. Ideally, this can be completed as a concurrent or staged procedure with the use of laparoscopy.

Here, we present a case of a 34-year-old G2P2, who was referred to our centre due to her history of endometriosis and catamenial haemothoraces. She had previously been on a GnRH agonist. However, this was discontinued as she was hoping to conceive. Her past medical history of significant for anaemia and endometriosis, as well as recurrent haemothoraces. She was not on any regular medications and had no known drug allergies. She had no significant social or family history to report.

Her surgical history was significant for an umbilical hernia repair, complicated by a small bowel injury, for which a resection and primary anastomosis was completed. She subsequently required a second hernia repair with mesh, due to recurrence of the hernia. She had three thoracenteses, due to her haemothoraces with chest tube placement. The options for proceeding were reviewed extensively with the patient, and she preferred to proceed surgically, as she planned to conceive as quickly as possible. We discussed both a staged or concurrent procedure that included both VATS and laparoscopy.

She was subsequently seen by thoracic surgery with a plan to proceed with combined VATS and laparoscopy. Unfortunately, the patient deteriorated, presenting to the hospital with bilateral effusions. Given her clinical status, she consented to proceed with a left-sided VAT.

Here you can see we are in the left thoracic cavity, looking up from the caudal view. The lung and the diaphragm are readily seen. An assessment of the chest cavity was completed, and the patient was noted to have a significant amount of blood in the left hemithorax. The blood was then suctioned out. An adhesion between the lung and the diaphragm was identified. This was then resected using a monopolar instrument.

A wedge resection was then completed in order to remove the abnormal tissue on the inferior aspect of the lung. The camera was then repositioned to look from a [unclear] direction. A soft tissue adherence was visualised on the diaphragm. Further abnormal tissue was identified. This was resected from the diaphragm, using a monopolar instrument. The area was then interrogated with a suction irrigator, and was noted to be soft and free from any further nodularity.

We then returned to the soft tissue adherence and began mobilising it from the diaphragm. This revealed omentum protruding from the diaphragm into the chest cavity. This nodule was then resected, and then ultimately sent to pathology. The defect in the diaphragm was visualised after reducing the omentum back into the abdominal cavity. Here, you can see the spleen inferior to the diaphragm.

The defect in the diaphragm was then repaired. Copious amounts of irrigation was completed. An intercostal nerve block was then completed to assist with post-operative pain.

In conclusion, these patients should be managed by a multidisciplinary team. The initial surgical approach should be minimally invasive, with either combined or staged VATS plus laparoscopy. Considerations to prepare for a seamless OR include a flex table to allow for appropriate positioning during VATS, an anaesthesia consult to prepare for double lumen intubation and PCA setup. And working with nursing staff to ensure that all equipment is ready for the OR.

Since her procedure, our patient has been doing very well. Her pain has improved, and she’s had a resolution of her symptoms. She’s currently attempting to conceive. Thank you for your time.