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Thoracic Surgery: Current Practice and Future Directions
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Thoracic Surgery: Current Practice and Future Directions

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Respiratory Medicine".

Deadline for manuscript submissions: closed (31 March 2025) | Viewed by 9994

Special Issue Editor

Dr. Dania Nachira

E-Mail Website
Guest Editor
Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A. Gemelli", Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, 00168 Rome, Italy
Interests: lung; lung cancer; lung diseases; thoracic diseases; malignant pleural effusion; mesothelioma; mediastinal diseases; thoracic surgery; bronchoscopy
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

In the last few years, thoracic surgery has been experiencing a tremendous development in terms of new technologies, and innovations in minimally invasive approaches and in integrated strategies for oncological treatments.

This Special Issue aims to collect new evidence on the safety, efficacy and reproducibility of minimally invasive techniques, such as Uniportal-VATS and RATS, in lung, mediastinal and esophageal diseases. It also aims to delve deeper into the results of new oncological integrated strategies for treatment, such as the role of immunotherapy in the neoadjuvant protocols of therapy.

This Special Issue will also look into innovative management in thoracic anesthesiology and loco-regional blocks for pain management during minimally invasive approaches.

Original research articles and reviews are welcome.

Research areas may include (but are not limited to) the following:

  • Current evidence on NSCLC pathogenesis, modern strategies for integrated treatment and future perspectives;
  • Novel endoscopic diagnostic and therapeutic techniques in thoracic surgery;
  • Minimally invasive thoracic surgery (VATS and RATS);
  • New anesthesiology and pain management strategies in thoracic surgery.

I look forward to receiving your contributions.

Dr. Dania Nachira
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • NSCLC
  • mediastinum
  • thymoma
  • esophageal disease
  • immunotherapy
  • new technologies
  • minimally invasive surgery
  • VATS
  • RATS

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Related Special Issue

Published Papers (7 papers)

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Research

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11 pages, 917 KiB  
Article
A Smartphone App for the Management of Postoperative Home Recovery After Thoracic Surgery Procedures: A Pilot Study Using the Care4Today™ App
by Pietro Bertoglio, Elena Garelli, Silvia Bonucchi, Jury Brandolini, Kenji Kawamukai, Filippo Antonacci, Sergio Nicola Forti Parri, Barbara Bonfanti, Giulia Lai, Lisa De Leonibus and Piergiorgio Solli
J. Clin. Med. 2024, 13(24), 7843; https://doi.org/10.3390/jcm13247843 - 23 Dec 2024
Viewed by 1190
Abstract
Background/Objectives: In recent years, the use of smartphones has significantly increased among populations of almost every age. The aim of our work is to analyze the impact of an application (app) that follows up with the progress of a patient who underwent a [...] Read more.
Background/Objectives: In recent years, the use of smartphones has significantly increased among populations of almost every age. The aim of our work is to analyze the impact of an application (app) that follows up with the progress of a patient who underwent a thoracic surgery procedure in the first 30 days after discharge. Methods: We prospectively analyzed all the patients included in the pilot study from March 2023 to September 2023. The Care4Today™ app was downloaded and activated by the patient preoperatively. From the day of discharge, the app sent questions related to pain perception, breathing capacity, general clinical conditions, problems with surgical wound and quality of life. In the case of negative responses, clinical staff received an email with an orange (medium problem) or red (serious problem) alert. Results: Among the 96 patients who were included, 82 eventually downloaded and used the app. The mean age of the patients was 60.7 years (range 19–80), and 43 (52.4%) were female. Minimally invasive techniques (VATS or RATS) were used in 76 cases (92.7%). The mean length of in-hospital stay was 5.3 days. Malignancy was the reason for surgery in 66 cases (80.5%). The answer rate was 75.8%. A total of 698 orange alerts and 52 red alerts were sent by the app. Re-hospitalization was needed in two cases (only one case related to our surgical procedure). The app was globally judged as useful in the management of convalescence (with an average rating of 7.4 out of 10). Age was not related to the completion rate of answers. Conclusions: The use of the app Care4Today could prevent unexpected re-hospitalization and possible complications. The patients appreciated the use of this tool, and they found it useful for safer postoperative recovery. No difference according to the patients’ age was found regarding the use of the app. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
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13 pages, 1605 KiB  
Article
Goal-Directed Fluid Therapy Using Pulse Pressure Variation in Thoracic Surgery Requiring One-Lung Ventilation: A Randomized Controlled Trial
by Giovanni Punzo, Giovanna Beccia, Chiara Cambise, Tiziana Iacobucci, Flaminio Sessa, Mauro Sgreccia, Teresa Sacco, Angela Leone, Maria Teresa Congedo, Elisa Meacci, Stefano Margaritora, Liliana Sollazzi and Paola Aceto
J. Clin. Med. 2024, 13(18), 5589; https://doi.org/10.3390/jcm13185589 - 20 Sep 2024
Cited by 2 | Viewed by 912
Abstract
Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung [...] Read more.
Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO2)/ fraction of inspired oxygen (FiO2) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO2/FiO2 ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO2/FiO2 ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
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9 pages, 1866 KiB  
Article
Ultrasound for Intra-Operative Detection of Peri-Centimetric Pulmonary Nodules in Uniportal Video-Assisted Thoracic Surgery (VATS): A Comparison with Conventional Techniques in Multiportal VATS
by Sebastiano Angelo Bastone, Alexandro Patirelis, Matilde Luppichini and Vincenzo Ambrogi
J. Clin. Med. 2024, 13(15), 4448; https://doi.org/10.3390/jcm13154448 - 29 Jul 2024
Cited by 1 | Viewed by 1169
Abstract
Background: Video-assisted thoracic surgery (VATS) has become the gold-standard approach for lung resections. Given the impossibility of digital palpation, we witnessed the progressive development of peri-centimetric and deeply located pulmonary nodule alternative detection techniques. Intra-operative lung ultrasound is an increasingly effective diagnostic method, [...] Read more.
Background: Video-assisted thoracic surgery (VATS) has become the gold-standard approach for lung resections. Given the impossibility of digital palpation, we witnessed the progressive development of peri-centimetric and deeply located pulmonary nodule alternative detection techniques. Intra-operative lung ultrasound is an increasingly effective diagnostic method, although only a few small studies have evaluated its accuracy. This study analyzed the effectiveness and sensitivity of uniportal VATS with intra-operative lung ultrasound (ILU), in comparison to multiportal VATS, for visualizing solitary and deep-sited pulmonary nodules. Methods: Patient data from October 2021 to October 2023, from a single center, were retrospectively gathered and analyzed. In total, 31 patients who received ILU-aided uniportal VATS (Group A) were matched for localization time, operative time, sensitivity, and post-operative complications, with 33 undergoing nodule detection with conventional techniques, such as manual or instrumental palpation, in multiportal VATS (Group B). Surgeries were carried out by the same team and ILU was performed by a certified operator. Results: Group A presented a significantly shorter time for nodule detection [median (IQR): 9 (8–10) vs. 14 (12.5–15) min; p < 0.001] and operative time [median (IQR): 33 (29–38) vs. 43 (39–47) min; p < 0.001]. All nodules were correctly localized and resected in Group A (sensitivity 100%), while three were missed in Group B (sensitivity 90.9%). Two patients in Group B presented with a prolonged air leak that was conservatively managed, compared to none in Group A, resulting in a post-operative morbidity rate of 6.1% vs. 0% (p = 0.16). Conclusions: ILU-aided uniportal VATS was faster and more effective than conventional techniques in multiportal VATS for nodule detection. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
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13 pages, 3863 KiB  
Article
Are the Efficacy and Safety of Chest Tubes in Uniportal Video-Assisted Thoracic Surgery Related to the Level of Intercostal Space Insertion or to the Drain Type? A Prospective Multicenter Study
by Dania Nachira, Pietro Bertoglio, Mahmoud Ismail, Antonio Giulio Napolitano, Giuseppe Calabrese, Khrystyna Kuzmych, Maria Teresa Congedo, Carolina Sassorossi, Elisa Meacci, Leonardo Petracca Ciavarella, Marco Chiappetta, Filippo Lococo, Piergiorgio Solli and Stefano Margaritora
J. Clin. Med. 2024, 13(2), 430; https://doi.org/10.3390/jcm13020430 - 12 Jan 2024
Cited by 5 | Viewed by 1644
Abstract
Objectives: The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial [...] Read more.
Objectives: The aim of this study is to evaluate if the efficacy and safety of chest tube placement are influenced by the level of intercostal space insertion (uniportal VATS vs. biportal VATS) or by the type of drain employed (standard vs. smart coaxial drain). Methods: Data on patients who underwent either uniportal or biportal VATS upper lobectomies with lymphadenectomy were prospectively collected in three European centers. The uniportal VATS group with a 28 Fr standard chest tube (U-VATS standard) was compared with the uniportal VATS group with a 28 Fr smart drain (U-VATS smart), and U-VATS smart was also compared with biportal VATS with a 28 Fr smart drain inserted in the VIII intercostal space (Bi-VATS smart). Results: When comparing the U-VATS standard group with the U-VATS smart, a higher fluid output was recorded in the U-VATS smart (p: 0.004) in the III post-operative day (p.o.) and overall (p: 0.027), with a lower 90-day re-admission in the U-VATS smart (p: 0.04). The Bi-VATS smart group compared to U-VATS smart showed a higher fluid output in the I p.o. (p < 0.001), with no difference in total fluid amount or hospitalization. The Bi-VATS smart recorded a lower incidence (p < 0.001) of residual pleural space or effusion (p: 0.004) at chest X-rays prior to drain removal but a higher level of pain and chronic intercostal neuralgia (p: 0.03). Conclusions: Chest tube insertion through the same incision space in uniportal VATS seems to be safe and effective. Smart drains can improve the fluid output in uniportal VATS, as if the drainage were inserted in a lower space (i.e., biportal VATS), but with less discomfort. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
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Review

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14 pages, 259 KiB  
Review
NSCLC: Current Evidence on Its Pathogenesis, Integrated Treatment, and Future Perspectives
by Kareem Tahayneh, Mayar Idkedek and Firas Abu Akar
J. Clin. Med. 2025, 14(3), 1025; https://doi.org/10.3390/jcm14031025 - 6 Feb 2025
Viewed by 2433
Abstract
Non-small cell lung carcinoma (NSCLC) comprises the majority of lung cancer cases, characterized by a complex interplay of genetic alterations, environmental factors, and molecular pathways contributing to its pathogenesis. This article highlights the multifaceted pathogenesis of NSCLC and discusses screening and integrated strategies [...] Read more.
Non-small cell lung carcinoma (NSCLC) comprises the majority of lung cancer cases, characterized by a complex interplay of genetic alterations, environmental factors, and molecular pathways contributing to its pathogenesis. This article highlights the multifaceted pathogenesis of NSCLC and discusses screening and integrated strategies for current treatment options. NSCLC is an evolving field with various aspects including the underlying molecular alterations, oncogenic driver mutations, and immune microenvironment interactions that influence tumor progression and response to therapy. Surgical treatment remains the most applicable curative option, especially in the early stages of the disease, adjuvant chemotherapy may add benefits to previously resected patients. Combined Radio-chemotherapy can also be used for palliative purposes. There are various future perspectives and advancing horizons in NSCLC management, encompassing novel therapeutic modalities and their applications, such as CAR-T cell therapy, antibody-drug conjugates, and gene therapies. On the other hand, it’s crucial to highlight the efficacy of innovative modalities of Immunotherapy and immune checkpoint inhibitors that are nowadays widely used in treatment of NSCLC. Moreover, the latest advancements in molecular profiling techniques and the development of targeted therapies designed for specific molecular alterations in NSCLC play a significant role in its treatment. In conclusion, personalized approaches are a cornerstone of successful treatment, and they are based on a patient’s unique molecular profile, tumor characteristics, and host factors. Entitling the concept of individualized treatment strategies requires proper patient selection, taking into consideration mechanisms of resistance, and investigating potential combination therapies, to achieve the optimal impact on long-term survival. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
11 pages, 238 KiB  
Review
Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery?
by Federico Raveglia, Angelo Guttadauro, Ugo Cioffi, Maria Chiara Sibilia and Francesco Petrella
J. Clin. Med. 2024, 13(11), 3193; https://doi.org/10.3390/jcm13113193 - 29 May 2024
Viewed by 1379
Abstract
Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. [...] Read more.
Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. Because autonomic nervous system surgery is a high-precision surgery, it is conceivable that the application of RATS could lead to improved outcomes and reduced side effects, but its feasibility has not yet been thoroughly studied. This review identified three main areas of application: (1) standard thoracic sympathectomy, (2) selective procedures, and (3) nerve reconstruction. Regarding standard sympathectomy and its usual areas of application, such as the management of hyperhidrosis and some cardiac and vascular conditions, the use of RATS is almost anecdotal. Instead, its impact can be decisive if we consider selective techniques such as ramicotomy, optimizing selective surgery of the communicating gray branches, which appears to reduce the incidence of compensatory sweating only when performed with the utmost care. Regarding sympathetic nerve reconstruction, there are several studies, although not conclusive, that point to it as a possible solution to reverse surgical nerve interruption. In conclusion, the characteristics of RATS might make it preferable to other techniques and, particularly, VATS, but to date, the data in the literature are too weak to draw any evidence. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)

Other

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13 pages, 234 KiB  
Perspective
From Awake to Minimalist Spontaneous Ventilation Thoracoscopic Lung Surgery: An Ongoing Journey
by Eugenio Pompeo
J. Clin. Med. 2025, 14(7), 2475; https://doi.org/10.3390/jcm14072475 - 4 Apr 2025
Viewed by 264
Abstract
Spontaneous ventilation lung surgery (SVLS) without intubation is aimed at avoiding adverse effects of mechanical ventilation lung surgery (MVLS) entailing one-lung mechanical ventilation through a double-lumen tracheal tube. This innovative strategy has evolved following the publication of a small randomized study of thoracoscopic [...] Read more.
Spontaneous ventilation lung surgery (SVLS) without intubation is aimed at avoiding adverse effects of mechanical ventilation lung surgery (MVLS) entailing one-lung mechanical ventilation through a double-lumen tracheal tube. This innovative strategy has evolved following the publication of a small randomized study of thoracoscopic pulmonary wedge resection carried out under spontaneous ventilation without tracheal intubation in fully awake patients. It now entails target-controlled sedation, the use of a laryngeal mask, and thoracic analgesia by intercostal or paravertebral blocks and has shown promise both in unicenter and multicenter studies, resulting in optimal feasibility and safety and highly satisfactory results, particularly in patients undergoing lung cancer resection and metastasectomy, lung biopsy for undetermined interstitial lung disease, lung volume reduction surgery for end-stage emphysema, and bullectomy for primary and secondary spontaneous pneumothorax. However, concerns and unresolved issues still exist regarding the advantages and disadvantages of SVLS as well as the identification of optimal indications. This perspective is aimed at providing a critical overview of the current knowledge about SVLS with emphasis on recent data comparing the results with those of MVLS published in the last 10 years. Full article
(This article belongs to the Special Issue Thoracic Surgery: Current Practice and Future Directions)
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