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Communications to the Editor |

Catamenial Pneumothorax : An Example of Porous Diaphragm Syndromes FREE TO VIEW

Paul A. Kirschner, MD, FCCP
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Mount Sinai Medical Center New York, NY

Correspondence to: Paul A. Kirschner, MD, FCCP, Cardiothoracic Surgery, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029



Chest. 2000;118(5):1519-1520. doi:10.1378/chest.118.5.1519-a
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To the Editor:

I would like to comment on the letter of Funatsu et al (December 1999),1 concerning the relationship of catamenial pneumothorax to the peritoneal stomata of the diaphragm.

I do not believe that the peritoneal stomata have anything to do with catamenial pneumothorax, much less Meigs’ syndrome or the many other examples of transdiaphragmatic passage of gases, fluids, blood, tissue, chyle, and other substances from the abdominal cavity to the pleural space.

I have characterized these clinical phenomena as porous diaphragm syndromes2 because of their common feature, a defect in the diaphragm.

Certainly, peritoneal stomata do exist, having been demonstrated by silver stains by von Recklinghausen3in 1862 and by many others, long before the observations of Allen4in 1936 and more recently by Li and Yu5 in 1991. But these stomata are tiny, requiring electron microscopy and scanning electron microscopy to demonstrate them. They are hardly large enough to account for the massive and rapid transfer of gases (as occurs in catamenial pneumothorax and artificial pneumoperitoneum with pneumothorax), fluids (found in cirrhosis of the liver with hepatic hydrothorax and peritoneal dialysis), blood (occurring in hemoperitoneum with bloody pleural effusion), and even chyle.

Such conditions are best explained by the presence of gross defects in the diaphragm, which have been demonstrated repeatedly at thoracotomy, thoracoscopy,6and autopsy.7 Strangely enough, such defects have yet to be observed in Meigs’ syndrome, although Drs. Edward Churchill and Richard Sweet, (eminent Harvard thoracic surgeons, both quoted by Meigs) assumed them to be present and, therefore, to account for the hydrothorax.2

Why the right-sided thoracic predominance? I believe that spikes of intraperitoneal pressure in the right subphrenic space accompanying respiratory activity and physical exertion, with the solid fixed liver acting as a piston, are responsible. In contrast, the loose arrangement and increased mobility of the left subphrenic organs minimize such pressure changes under the left hemidiaphragm.

Finally, if the peritoneal stomata theory were correct, every case of cirrhosis with ascites and every peritoneal dialysis should develop hydrothorax, and every case of pneumoperitoneum (spontaneous, as in catamenial pneumothorax, or induced, as in laparoscopy) should develop pneumothorax. Also, it would occur bilaterally with equal incidence. This is patently not the case.

Funatsu, K, Tsuru, M, Hayabuchi, N (1999) Catamenial pneumothorax and its relation to the peritoneal stomata of the diaphragm [letter].Chest116,1843
 
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin North Am1998;8,449-472
 
von Recklinghausen, F Zur fettresorption.Arch f Path Anat and Physiol and f Klinische Med1862;26,172-208
 
Allen, L The peritoneal stomata.Anat Rec1936;67,89-103
 
Li JC, Yu SM. Study on the ultra structure of the peritoneal stomata in humans. Acta Anat (Basel) 1991; 141:26–30.
 
Cowl, CT, Dunn, WF, Deschamps, C Visualization of diaphragmatic fenestration associated with catamenial pneumothorax.Ann Thorac Surg1999;68,1413-1414
 
Lieberman, FL, Peters, RL Cirrhotic hydrothorax: further evidence that an acquired diaphragmatic defect is at fault.Arch Intern Med1970;125,114-117
 

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References

Funatsu, K, Tsuru, M, Hayabuchi, N (1999) Catamenial pneumothorax and its relation to the peritoneal stomata of the diaphragm [letter].Chest116,1843
 
Kirschner, PA Porous diaphragm syndromes.Chest Surg Clin North Am1998;8,449-472
 
von Recklinghausen, F Zur fettresorption.Arch f Path Anat and Physiol and f Klinische Med1862;26,172-208
 
Allen, L The peritoneal stomata.Anat Rec1936;67,89-103
 
Li JC, Yu SM. Study on the ultra structure of the peritoneal stomata in humans. Acta Anat (Basel) 1991; 141:26–30.
 
Cowl, CT, Dunn, WF, Deschamps, C Visualization of diaphragmatic fenestration associated with catamenial pneumothorax.Ann Thorac Surg1999;68,1413-1414
 
Lieberman, FL, Peters, RL Cirrhotic hydrothorax: further evidence that an acquired diaphragmatic defect is at fault.Arch Intern Med1970;125,114-117
 
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