Comment to the article: Diaphragmatic patch: A useful adjunct in surgical treatment of recurrent catamenial hemothorax

Abstract

The present work reviews the catamenial hemothorax and its relation to two potential clinical cases. Hemothorax is a condition usually associated to thoracic trauma, iatrogenesis, pneumothorax, and malignant or infectious pleural disease. Apart from these clinical entities, the presence of hemothorax is not frequent and its etiology is usually difficult to ascertain. Thoracic endometriosis1,2 is one of the rare entities that can be responsible for the presentation of a hemothorax, and the diagnosis is relatively easy when endometriosis foci are found within the thoracic cavity. More frequently, hemothorax is clinically diagnosed in female patients with abdominal endometriosis presenting pneumothorax and/or hemothorax associated with the end phase of the menstrual cycle.2,3 Other cases are usually labelled as idiopathic cases. Regarding the treatment, the use of drainage alone can be sufficient; as a matter of fact, autologous blood was injected in the pleural space as the treatment for pneumothorax since it facilitates the development of pleural adherences.4,5 Cleaning of pleural cavity through videothoracoscopy, combined with pleural and diaphragmatic abrasion, could facilitate the diagnosis and, at the same time, solve the problem.2,3 In case of relapse, total or partial parietal pleurectomy could be a more aggressive option for the management of this entity. In every case, pleural examination and lung palpation should be done in order to identify the presence of lung bullas, endometriosis foci or nodules that should be resected for diagnosis and treatment purposes. The diaphragm should be carefully inspected for the identification and closure with suture of orifices that can be occasionally found. was considered an absolute contraindication to lung transplant. Nowadays, the International Society of Heart and Lung Transplantation still consider talc poudrage as a very high surgical and postoperative risk factor.6 All of us who have performed transplant surgery in patients previously treated with talc pleurodesis know the intense pleural reaction against talc, which can be especially problematic when fibrosis affects vascular and mediastinal structures. The use of talc in patients of 30--40 years of age who may require a transplant or any other thoracic surgical intervention in the future should be approached with great caution. In these cases the reconstruction of the diaphragm with a Gore-Tex patch has been effective,7 but it is a very arduous task, expensive and, probably unnecessary, especially when no transdiaphragmatic orifices or significant diaphragmatic pathology are observed. The end may justify the use of exceptional means in, especially, complex cases, but it never justifies the recommendation of those means as routine treatment. In conclusion, we should always be extremely thorough in the fulfilment of diagnostic criteria and very cautious when we use or recommend therapeutic procedures that are not yet well established or are not free from future complications.