Multidisciplinary Treatment for Thoracic and Abdominopelvic Endometriosis
Open accessAbstract
BACKGROUND AND OBJECTIVES: Thoracic endometriosis is a rare form of extragenital endometriosis with important clinical ramifications. Up to 80% of women with thoracic endometriosis have concomitant abdominopelvic endometriosis, yet the surgical treatment is usually performed with separate procedures. This is the largest published series of the combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic and thoracic endometriosis. The objectives of this series are to further evaluate the manifestations of thoracic endometriosis, assess the multidisciplinary surgical approach, and discuss our institution's protocols. METHODS: This is a retrospective, institutional review board-approved case series of 25 consecutive women who underwent combined video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of abdominopelvic, diaphragmatic, and thoracic endometriosis from January 1, 2008, to September 30, 2013. All surgeries were performed at a tertiary referral center by the same primary surgeons. Data were collected by chart review. RESULTS: Twenty-five patients were included, with a mean age of 37.7 years. Eighty percent of patients had catamenial chest pain, and in 40% this was their only chest complaint. Shoulder pain was noted in 40% of patients, catamenial pneumothorax in 24%, and hemoptysis in 12%. One hundred percent of patients were found to have endometriosis in the pelvis, 100% in the diaphragm, 64% in the chest wall, and 40% in the parenchyma. There were 2 major postoperative complications: 1 diaphragmatic hernia and 1 vaginal cuff hematoma. CONCLUSION: Clinical suspicion and preoperative assessment are crucial in the diagnosis of thoracic endometriosis and allow for a multidisciplinary approach. The combination of video-assisted thoracoscopic surgery and traditional laparoscopy for the treatment of endometriosis optimally addresses the pelvis, diaphragm, and thoracic cavity in a single operation.
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The most common site of endometriosis outside the abdominopelvic cavity is the thoracic cavity.
“The most common site of endometriosis outside of the abdominopelvic cavity is within the thoracic cavity8–10”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [10]
The Introduction (page unavailable) lists the thoracic cavity among sites of extragenital endometriosis, and the Discussion describes thoracic endometriosis as a rare form. Neither section compares its frequency with other sites outside the abdominopelvic cavity, so the claim that it is the most common such site is unsupported. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThere is significant variety in the morphological appearance of endometriotic lesions, with clear vesicular lesions, fibrotic white lesions, and liver adhesions reported.
“However, there is significant variety in the morphological appearance of endometriotic lesions with clear vesicular lesions, fibrotic white lesions, and liver adhesions reported.10,37”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [10]
The Results report fibrosis in lung-resection specimens, and a figure caption in the Discussion shows an endometriosis-related adhesion between the lung and chest wall. Neither passage describes clear vesicular or fibrotic white lesions, and the reported adhesion is not to the liver. The Methods discuss examining the liver but do not report liver adhesions. (LLM, conf=0.79)
Experimental — accuracy not yet measuredIsolated diaphragmatic endometriosis is typically asymptomatic but can result in irritation of the phrenic nerve, producing catamenial pain.
“Outside of the well-established clinical manifestations of TES, cases of isolated diaphragmatic endometriosis are typically asymptomatic but can result in irritation of the phrenic nerve. This can produce a syndrome of only catamenial pain, presenting as cyclic neck, shoulder, right upper quadrant, or epigastric pain.2,9,10,31,35–37”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [10]
The Discussion reports catamenial chest pain and shoulder pain in patients with thoracic endometriosis, sometimes without another chest complaint. It does not establish that isolated diaphragmatic endometriosis is typically asymptomatic, attribute pain to phrenic-nerve irritation, or describe the full range of pain sites claimed. Page numbers are unavailable in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredDiagnosis of thoracic endometriosis by endoscopic visualization can be delayed due to traditional focus on pelvic disease, variable appearance of endometriotic lesions, and unseen posterior diaphragmatic disease hidden behind the liver.
“The diagnosis of thoracic endometriosis by endoscopic visualization can be delayed due to a traditional focus on pelvic disease, the variable appearance of endometriotic lesions, and unseen posterior diaphragmatic disease hidden behind the liver.10,37”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [10]
The Methods (page unavailable) describe moving the liver to view the adjacent diaphragm, and the Discussion says liver bulk can limit access to diaphragmatic disease. The Discussion also supports the need to assess thoracic as well as pelvic disease. It does not attribute delayed endoscopic diagnosis to a traditional pelvic focus or to variation in the visual appearance of lesions, nor does it specifically describe posterior diaphragmatic disease hidden behind the liver. (LLM, conf=0.82)
Experimental — accuracy not yet measuredEndometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, and pulmonary nodules, collectively known as thoracic endometriosis syndrome (TES).
“Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations, including catamenial pneumothorax, catamenial hemothorax, catamenial hemoptysis, and pulmonary nodules. Collectively, this is known as thoracic endometriosis syndrome (TES).8–10”
From Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management (2019) · cites this paper as [10]
For thoracic endometriosis, hormone treatment can be offered.
“For thoracic endometriosis, hormone treatment can be offered.”
From ESHRE guideline: endometriosis (2022) · cites this paper as Nezhat et al., 2014
The most common symptoms associated with CP are chest or shoulder pain, cough, dyspnea, and shortness of breath.
“The most common symptoms associated with CP are chest or shoulder pain, cough, dyspnea, and shortness of breath.”
From Extra-pelvic endometriosis: a review. (2020) · cites this paper as [72]
Nezhat et al reported that TE was found in diaphragm (100%), chest wall (64%), and parenchyma (64%) using the VATS procedure.
“Nezhat et al reported that TE was found in diaphragm (100%), chest wall (64%), and parenchyma (64%) using the VATS procedure.”
From Extra-pelvic endometriosis: a review. (2020) · cites this paper as [72]
Extra abdominopelvic manifestations of endometriosis are more commonly located in the thorax.
“A sizable number of extra abdominopelvic manifestations have been described, more commonly in the thorax [ 6 , 7 , 8 , 9 , 10 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
Without a high index of suspicion, the diagnosis of thoracic endometriosis syndrome can be delayed.
“Without a high index of suspicion, the diagnosis can be delayed [ 8 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
Suspicion of thoracic endometriosis syndrome is primarily based on the patient's history, which is sufficiently sensitive to recommend surgical intervention when appropriate.
“The suspicion of TES is primarily based on the patient’s history, which is sufficiently sensitive to recommend surgical intervention when appropriate [ 8 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
In a 2014 retrospective observational study, 25 patients underwent VATS with video laparoscopy for thoracic, diaphragmatic, and abdominopelvic endometriosis without pleurodesis, and no recurrent pneumothorax were found in the 3- to 18-month follow-up period.
“In 2014, we reported a retrospective observational study wherein 25 patients underwent VATS with video laparoscopy for thoracic, diaphragmatic, and abdominopelvic endometriosis without the use of pleurodesis, and no reports of recurrent pneumothorax were found in the 3-month to 18-month follow-up period [ 8 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
In a 2014 retrospective observational study of 25 patients with TES, 76% had both pleural and abdominal diaphragm involvement.
“In our 2014 retrospective observational study of 25 patients, we reported that 76% of patients with TES had both pleural and abdominal diaphragm involvement [ 8 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
The use of monopolar energy is discouraged due to proximity to the heart and the risk of cardiac arrhythmias, as well as potential muscular contractions.
“The use of monopolar energy is discouraged due to the proximity to the heart and the risk of cardiac arrhythmias, as well as potential muscular contractions [ 8 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
Concomitant pelvic endometriosis is frequent in thoracic endometriosis syndrome.
“Concomitant pelvic endometriosis is frequent, and video laparoscopy at time of VATS is recommended [ 8 , 22 ].”
From Thoracic Endometriosis Syndrome: A Comprehensive Review and Multidisciplinary Approach to Management (2024) · cites this paper as [8]
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The History of Non-obstetric Endoscopic Surgery During Pregnancy
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Comment je fais … une résection d’endométriose diaphragmatique par voie cœlioscopique
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Կատամենիալ պնևմոթորաքս. կլինկական դեպքեր և գրականության տվյալների վերլուծություն
Ստեփանյան, Ռ., Դանիելյան, Շ., Ոսկանյան, Գ., Մատիկյան, Ս., Ավետիսյան, Ա., Առաքելյան, Գ., Ստեփանյան, Լ., Գեղամյան, Գ., Կոբելյան, Հ., & Բասենցյան, Մ. (2023) · Armenian Journal of Health & Medical Sciences · doi:10.54235/27382737-2023.v3.2-95
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Endometriosis and Endometriosis-Associated Tumors
Simmen, R. C. M., Quick, C. M., & Zheng, W. (2025) · Springer eBooks · doi:10.1007/978-981-97-4822-8_12
NEZHAT, C. R., Nezhat, F. R., NEZHAT, C. R., Lakhi, N., & Nezhat, A. A. (2025) · Cambridge University Press eBooks · doi:10.1017/9781108561440.013
Self-citation
- Authors
- Nezhat, C., Main, J., Paka, C., Nezhat, A., & Beygui, R. E.
- Affiliations
- Stanford Medicine (US)
- Corresponding author
- Nezhat, Camran
- Venue
- JSLS : Journal of the Society of Laparoendoscopic Surgeons
- Published
- 2014
- Volume
- 18
- Issue
- 3
- Pages
- e2014.00312
- ISSN
- 1086-8089 (ISSN-L)
- 1938-3797
- PMC
- PMC4154426
- OpenAlex
- W2319230577
- Cited by
- 108
- References
- 30
- Citations by year
- 2026: 9 · 2025: 10 · 2024: 14 · 2023: 10 · 2022: 20 · 2021: 9 · 2020: 7 · 2019: 8 · 2018: 9 · 2017: 6 · 2016: 3 · 2015: 3
- FWCI
- 4.80
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc-nd
- Locations
- JSLS Journal of the Society of Laparoscopic & Robotic Surgeons (publishedVersion, cc-by-nc-nd)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion, cc-by-nc-nd)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Pleural and Pulmonary Diseases
- Health Sciences › Medicine › Obstetrics and Gynecology › Gynecological conditions and treatments
- Keywords
- thoracic endometriosis, diaphragmatic endometriosis, video-assisted thoracoscopic surgery, laparoscopic surgery, combined surgical approach, catamenial pneumothorax, shoulder pain, hemoptysis, diaphragmatic hernia, postoperative complications, multidisciplinary surgical management
- MeSH terms
- Adult, Endometriosis, Female, Humans, Middle Aged, Pelvis, Laparoscopy, Retrospective Studies, Thoracic Diseases, Thoracic Surgery, Video-Assisted
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