Surgical management of catamenial pneumothorax: a systematic review

Andrew Mekhail, Mekhail A, Kilby J, Joseph Kilby, Sam Macalister, Macalister S, Manivannan PC, Pravin Chidambaram Manivannan, Seitz M, Michael Seitz
Journal of cardiothoracic surgery · 2026 · vol. 21(1) · doi:10.1186/s13019-026-04227-1 · PMID:42063108 · PMC13281252 · W7159602312
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⚙ AI-generated summary by gemini-2.5-flash-lite, 2026-07-20 ⓘ

This systematic review found that multimodal management, including diaphragmatic surgery, pleurodesis, and postoperative hormonal therapy, significantly reduces catamenial pneumothorax recurrence rates.

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This systematic review evaluated published studies (2000–2025) reporting outcomes of surgical management for catamenial pneumothorax, a thoracic manifestation of thoracic endometriosis syndrome, extracting patient characteristics, surgical techniques (pleural and diaphragmatic interventions), postoperative hormonal therapy use, and recurrence rates. Across 37 studies with over 1,800 patients, the authors found recurrence depended strongly on the treatment approach, with pooled recurrence rates of 17.3% when postoperative hormonal therapy was used versus 54.2% without, and younger age associated with higher recurrence. Diaphragmatic intervention combined with pleurodesis showed lower recurrence (12.5%) than pleurodesis alone (100%), and diaphragm resection was reported as an independent protective factor (HR 0.16). The review emphasizes that evidence comes from observational data and should be interpreted cautiously. This paper is centrally about endometriosis—specifically catamenial pneumothorax as a rare manifestation of thoracic endometriosis syndrome and its surgical management.

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Abstract

BACKGROUND: Catamenial pneumothorax is a rare manifestation of thoracic endometriosis syndrome and is associated with a high risk of recurrence despite surgical intervention. Increasingly, multimodal strategies combining thoracic surgery with adjunctive hormonal therapy have been put in place as standard practice however, optimal management remains uncertain. METHODS: A systematic review of the literature was conducted using MEDLINE/PubMed, Scopus, CENTRAL, Google Scholar, SciSpace, and the Cochrane Library for studies published between January 2000 and December 2025. Studies reporting outcomes of surgical management for catamenial pneumothorax were included. Data was extracted on patient characteristics, surgical techniques (diaphragmatic and pleural interventions), use of postoperative hormonal therapy, and recurrence rates.  RESULTS: Analysis of 37 studies encompassing over 1,800 patients suggests that treatment approach is a major determinant of outcomes. Meta-analysis demonstrates a pooled recurrence rate of 17.3% with postoperative hormonal therapy compared to 54.2% without (p < 0.01) [1], with younger age independently associated with higher recurrence risk. Diaphragmatic intervention is critical to reducing recurrence, with studies reporting 12.5% recurrence when diaphragmatic surgery is combined with pleurodesis versus 100% with pleurodesis alone [15]. Diaphragm resection has been identified as an independent protective factor against recurrence (HR 0.16; 95% CI: 0.03-0.77; p = 0.022) [5]. CONCLUSIONS: The available evidence supports a multimodal approach to the management of catamenial pneumothorax. Comprehensive thoracoscopic surgery addressing diaphragmatic pathology, combined with pleurodesis and postoperative hormonal therapy, is consistently associated with reduced recurrence. Given the observational nature of the available data, these findings should be interpreted with appropriate caution and highlight the need for prospective, collaborative studies.
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Abstract

Background Catamenial pneumothorax is a rare manifestation of thoracic endometriosis syndrome and is associated with a high risk of recurrence despite surgical intervention. Increasingly, multimodal strategies combining thoracic surgery with adjunctive hormonal therapy have been put in place as standard practice however, optimal management remains uncertain.

Methods

A systematic review of the literature was conducted using MEDLINE/PubMed, Scopus, CENTRAL, Google Scholar, SciSpace, and the Cochrane Library for studies published between January 2000 and December 2025. Studies reporting outcomes of surgical management for catamenial pneumothorax were included. Data was extracted on patient characteristics, surgical techniques (diaphragmatic and pleural interventions), use of postoperative hormonal therapy, and recurrence rates.

Results

Analysis of 37 studies encompassing over 1,800 patients suggests that treatment approach is a major determinant of outcomes. Meta-analysis demonstrates a pooled recurrence rate of 17.3% with postoperative hormonal therapy compared to 54.2% without (p < 0.01) [1], with younger age independently associated with higher recurrence risk. Diaphragmatic intervention is critical to reducing recurrence, with studies reporting 12.5% recurrence when diaphragmatic surgery is combined with pleurodesis versus 100% with pleurodesis alone [15]. Diaphragm resection has been identified as an independent protective factor against recurrence (HR 0.16; 95% CI: 0.03–0.77; p = 0.022) [5].

Conclusions

The available evidence supports a multimodal approach to the management of catamenial pneumothorax. Comprehensive thoracoscopic surgery addressing diaphragmatic pathology, combined with pleurodesis and postoperative hormonal therapy, is consistently associated with reduced recurrence. Given the observational nature of the available data, these findings should be interpreted with appropriate caution and highlight the need for prospective, collaborative studies. Similar content being viewed by others Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author information Authors and Affiliations Corresponding author Ethics declarations Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. About this article Cite this article Mekhail, A., Kilby, J., Macalister, S. et al. Surgical management of catamenial pneumothorax: a systematic review. J Cardiothorac Surg (2026). https://doi.org/10.1186/s13019-026-04227-1 Received: Accepted: Published: DOI: https://doi.org/10.1186/s13019-026-04227-1

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Condition tags

endometriosisthoracic_endometriosis

MeSH descriptors

Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis Endometriosis

Citation neighborhood

Papers in the corpus that this work cites (lower rings, blue) and that cite this one (upper rings, green). Dot size scales with the paper's in-corpus citation count — bigger dot = more influential within the endo/adeno field. Click a dot to open that paper. [ expand to 2 hops ] — adds papers reached through this work's immediate citers/citees. Heavier; up to 60 extra dots.

References (43)

SciLite annotations

organisms 3
noordeloos 2009062 noordeloos 2009062 noordeloos 2009062
chemicals 17
prostaglandin prostaglandin dienogest progestin talc polyurethane polymer glycolic acid polyester polymer estrogen progestin estrogen progestin estrogen progesterone talc talc talc

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