Beyond the pelvis: diagnostic and surgical challenges of thoracic endometriosis syndrome - a retrospective cohort study of 41 patients

Objective This study provides a comprehensive analysis of surgically managed thoracic endometriosis syndrome (TES) patients, primarily assessing whether diaphragmatic reconstruction is associated with lower postoperative recurrence. Secondarily, the study aims to evaluate histopathological findings and temporal changes in management of TES at a tertiary care center. Methods This retrospective study of 41 female patients (median age 37) treated surgically for TES between 2012 and 2025 at the Department of Thoracic Surgery, Medical University of Gdansk, Poland. Patients presenting with pneumothorax and/or symptoms of diaphragmatic endometriosis were stratified into Early and Late periods to evaluate changes in surgical management - video-assisted thoracoscopic surgery (VATS), thoracotomy, thoracolaparoscopy, and the implementation of accurate immunohistochemical histopathological assessment. Results Complete follow-up was available for 78.0% of patients, however, with differential loss to follow-up between groups (4.5% reconstruction vs. 42.1% no reconstruction; p = 0.006) may have biased results, with the direction of bias depending on the outcomes of patients lost to follow-up. Among patients with complete follow-up, intervention-requiring recurrence occurred in 0% of women with reconstruction versus 27.3% without reconstruction (Fisher exact p = 0.033). Among patients treated since 2022, diaphragmatic reconstruction was more frequent than in 2012–2021 (71.4% vs. 35.0%, p = 0.029). Routine immunohistochemical staining since 2022 improved histopathological confirmation of TES (90% vs. 0%; p 0.001). Conclusion In the study, diaphragmatic reconstruction was associated with lower intervention-requiring recurrence, which may indicate a potential benefit of reconstructive techniques in TES surgery. Routine immunohistochemical evaluation (ER, PR, CD10) may be essential for TES diagnosis.