Expectant management of asymptomatic diaphragmatic endometriosis: a cross-sectional retrospective study

This study aims to introduce 55 patients with diaphragmatic endometriosis (DEM) who managed by pelvic endometriosis resection without resection of DEM. Also, tries to identify the most appropriate theory of DEM pathogenesis by multivariant analysis.

55 patients who underwent diagnostic and therapeutic laparoscopic endometriosis surgery and were diagnosed with DEM during the operation were included. Only one of the patients had symptoms of DEM and another 54 were asymptomatic. The #ENZIAN classification was used to better describe pre-operative imaging and surgical findings. During the follow-up period, all patients were asked for any DEM symptoms. Also, a second-look exploratory laparoscopy was performed on four patients with severe DEM. No patient recieved post-operative hormonal therapy after pelvic endometriosis resection.

The mean age was 32.7 years. Dysmenorrhea was the most common symptom among patients (81%). 94.5% had co-existing endometrioma, and 98.2% had deep pelvic endometriosis. Also, 75% of patients had evidence of ovarian chocolate cyst leakage. The present study revealed that DEM laterality was significantly associated with right-sided endometrioma and rectovaginal endometriosis size, as patients with bilateral DEM were more likely to have larger right-sided endometrioma and rectovaginal endometriosis. During a mean follow-up period of 34 months, none of the asymptomatic patients developed symptoms, while one symptomatic patient reported an improvement in chest pain. Also, the second laparoscopic exploration was performed in four patients, and it revealed improvement of DEM implantations in three and progression in one.

In conclusion, DEM is a rare presentation of endometriosis that does not have a standardized diagnosis and treatment protocol. According to cases of DEM, which can be asymptomatic, subphrenic space exploration with appropriate exposure is necessary. In our opinion, the key point of the DEM treatment in asymptomatic patients is the current treatment of pelvic endometriosis. With pelvic endometriosis resection, DEM regresses spontaneously. In our study population, no patients with expectant management of the DEM mentioned related symptoms of DEM in follow-up visits. The results of this study emphasize the need for further studies on the expectant management of DEM.