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J Thorac Cardiovasc Surg 2005;129:1199
© 2005 The American Association for Thoracic Surgery
Letters to the Editor |
Unité de Chirurgie Thoracique Hotel-Dieu Hospital 1, Place du Parvis Notre-Dame Paris 75004, France
To the Editor:
We read with interest the article by Korom and associates1 reporting 3 new cases of catamenial pneumothorax and with an excellent review of the literature. The reports outline the frequent lack of recognition of diaphragmatic endometriosis as the causative factor of catamenial pneumothorax, even in patients submitted to surgical exploration with video-assisted thoracoscopy. In a previous prospective study on catamenial pneumothorax,2 we pointed out that exploration of the whole thoracic cavity should be mandatory in these patients. We suggested that patients should be positioned in the posterolateral decubitus position to correctly explore the whole hemidiaphragm, which is often incompletely visualized if the patient is positioned as for a lateral thoracotomy.
We would like to comment on 2 points concerning the article by Korom and associates.1 First, they state that not all of a patient’s menses coincide with a pneumothorax, but each episode of a catamenial pneumothorax is associated with the menstrual flow. Definition of catamenial pneumothorax implies a strict temporal relationship with menses, and the condition has been often defined as a recurrent pneumothorax occurring within 72 hours from the onset of menstruation.2 However, the recurrent character in relation with the immediate premenstrual period has also been reported.3,4 It has been recently shown that a recurrent endometriosis-related pneumothorax might be observed also in the intermenstrual period.5 Therefore it has been suggested that thoracic endometriosis should be suspected in any case of recurrent pneumothorax in women of reproductive age, even when episodes occur out of the menstrual period.5
Second, Korom and associates1 proposed plication of the portion of diaphragm involved by endometriosis rather than excision and repair. Furthermore, in their opinion hormonal therapy should be considered as a secondary therapeutic option to be used in case of failure of surgical intervention: they adopted this strategy in one of the 3 patients. We do not agree with these suggestions. In our opinion resection of all the visible lesions (when technically feasible) should be carried out not only to optimally treat the cause of pneumothorax but also to avoid further intrathoracic spread of the disease.2 In the absence of a hormonal treatment, endometrial implants (which are left in place by simple plication) would continue to undergo cyclical changes, with possible consequences in terms of partial diaphragmatic disruption and formation of new holes. We think that patients should be offered the best chance of cure when the disease is first diagnosed. For this reason, we proposed surgical excision of the diseased structures, pleurodesis, and a short course of hormonal treatment.2 Pleural symphysis takes some weeks to be effective after surgical intervention, and if menstruation occurs before pleurodesis is achieved, a recurrence of pneumothorax will be likely.
References
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