Thoracic Endometriosis Surgery: Effective Intervention or Incomplete Solution?

Meta-analysis shows that modern VATS-based surgery alone does not fully control disease recurrence or postoperative burden in thoracic endometriosis

Key Points

Highlights:

• Surgery for thoracic endometriosis is associated with high recurrence and complication rates.
• There is an urgent need for standardized, multidisciplinary management strategies.

Importance:

• Thoracic endometriosis remains an underrecognized and complex form of extrapelvic disease.
• Understanding real-world surgical outcomes is essential for patient counseling, surgical planning, and development of evidence-based guidelines.

What's Done Here?

• This is a a systematic review and meta-analysis of surgical outcomes in thoracic endometriosis.
• Twenty-eight studies involving 1,182 patients treated over 25 years were included.
• Outcomes assessed included recurrence, reoperation, complications, air leak, chest tube duration, and hospital length of stay.
• Random-effects meta-analysis was used to generate pooled outcome estimates.

Key Results:

• Pneumothorax recurrence occurred in 28.2% of patients after surgery.
• Reoperation was required in 14.0% of cases.
• Overall postoperative complication rate was 30.8%.
• Prolonged air leak occurred in 24.2% of patients.
• Chest tubes remained in place for a mean of 4.4 days, and hospital stay averaged 6.1 days.

Strengths and Limitations:

• Strengths are: being the largest meta-analysis to date evaluating surgical outcomes in thoracic endometriosis; the inclusion of clinically relevant outcomes such as air leak and hospital stay provides new insights; high histological confirmation rates strengthen diagnostic validity.

• Limitations are: most included studies were retrospective and observational; high heterogeneity reflects variability in surgical techniques and postoperative care; the lack of standardized protocols limits comparability across studies; patient-reported outcomes and quality-of-life data were largely absent.

From the Editor-in-Chief – EndoNews

"Thoracic endometriosis syndrome (TES) remains one of the most under-recognized and clinically challenging manifestations of endometriosis, sitting at the intersection of gynecology, thoracic surgery, and chronic disease management. In this large systematic review and meta-analysis of 1182 surgically treated patients, Amin et al. provide the most comprehensive quantitative assessment to date of postoperative outcomes in TES, moving the field beyond recurrence rates alone by incorporating complications, chest tube duration, and hospital length of stay as clinically meaningful endpoints.

The findings are striking: despite modern VATS-based approaches, nearly one in three patients experience pneumothorax recurrence, and postoperative morbidity remains substantial. These data challenge the implicit assumption that surgery, even when technically successful, is definitively corrective for TES. Instead, the results reinforce the concept of TES as a chronic, multifocal, and biologically distinct form of endometriosis, where surgical excision addresses manifestations rather than disease biology. The high heterogeneity across studies further reflects the absence of standardized diagnostic pathways, surgical strategies, and postoperative protocols—an issue that continues to fragment care and outcomes.

Importantly, this analysis reframes success in TES surgery: prolonged chest drainage and extended hospitalization are not merely technical sequelae but indicators of systemic disease burden and incomplete disease control. The study therefore underscores the urgent need for integrated, protocol-driven multidisciplinary care, combining precise surgical mapping, optimized diaphragmatic and pleural strategies, and evidence-based hormonal modulation. Future progress will depend on prospective registries, standardized reporting of patient-reported outcomes, and mechanistic studies that clarify why thoracic disease recurs despite aggressive intervention. Until then, this work sets a new benchmark for transparency in surgical outcome reporting and provides a critical evidence base for redesigning TES care pathways."

Lay Summary

Thoracic endometriosis is a rare and often overlooked form of endometriosis in which tissue similar to the uterine lining grows in or around the lungs and chest cavity. It can cause serious and recurring symptoms, such as lung collapse (pneumothorax), chest pain, coughing up blood, or shortness of breath, often linked to the menstrual cycle.

Because of its rarity and complexity, many patients experience long delays in diagnosis and may undergo repeated treatments before receiving appropriate care.

In a large meta-analysis published in the Journal of Minimally Invasive Gynecology, a group of researchers from cardiothoracic surgery and endometriosis centers of UK analyzed surgical outcomes in more than 1,100 patients treated for thoracic endometriosis over a 25-year period. The goal was to understand how effective surgery is in controlling symptoms and preventing recurrence.

The analysis showed that while surgery is often necessary, it is not always curative.

Nearly one in three patients experienced a recurrence of pneumothorax after surgery, and about one in seven required repeat operations.

Complications were also common, including prolonged air leaks that required extended chest tube drainage and longer hospital stays than expected for minimally invasive procedures.

These findings suggest that thoracic endometriosis behaves more like a chronic condition than a one-time surgical problem.

Surgery can relieve symptoms and prevent emergencies, but long-term management is often required, combining surgery, hormonal therapy, and careful follow-up in experienced centers.

Research Source: https://pubmed.ncbi.nlm.nih.gov/41419079/