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Thoracic Surgery: Current Challenges and Future Perspectives

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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 (20 December 2025) | Viewed by 15022

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Special Issue Editors

Dr. Jon Zabaleta

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Guest Editor

Department of Thoracic Surgery, Donostia University Hospital, 20014 San Sebastián, Spain
Interests: thoracic surgery; minimally invasive surgery; lung cancer; lung metastasectomies; segmentectomies; 3D printing; artificial intelligence

Dr. José Luis Campo-Cañaveral de la Cruz

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Guest Editor

Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
Interests: thoracic surgery; lung transplantation; minimally invasive surgery; airway surgery; lung cancer surgery

Special Issue Information

Dear Colleagues,

This Special Issue aims to provide a comprehensive overview of the latest advancements, emerging trends and unresolved challenges in the field of thoracic surgery. In this Special Issue, we invite submissions that address various topics related to thoracic surgery, including, but not limited to, minimally invasive techniques, robotic-assisted surgeries, lung cancer management, esophageal disorders, mediastinal tumors, pleural diseases, thoracic trauma, lung transplantation, lung segmentectomies, pneumothorax, 3D printing, surgical planification and artificial intelligence. We encourage original research articles, review papers and perspectives that explore novel approaches, innovative technologies and evidence-based practices in thoracic surgery.

The goal of this Special Issue is to foster collaboration among researchers, clinicians and experts in the field, facilitating the exchange of knowledge and experiences. By highlighting the current challenges and future perspectives, we aim to enhance patient outcomes, optimize surgical techniques and shape the future of thoracic surgery.

We welcome contributions from researchers, surgeons and healthcare professionals working in the field of thoracic surgery. Manuscripts should adhere to the scope of clinical research and provide valuable insights into the advancements, challenges and future directions of thoracic surgery.

Dr. Jon Zabaleta
Dr. José Luis Campo-Cañaveral de la Cruz
Guest Editors

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 250 words) can be sent to the Editorial Office for assessment.

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

minimally invasive surgery
robotic-assisted thoracic surgery
lung cancer management
esophageal surgery
pleural diseases and interventions
thoracic trauma surgery
tracheal and bronchial surgery
thoracic endoscopy
lung transplantation
lung segmentectomy
3D printing
pneumothorax
surgical planification
education
simulation
artificial intelligence

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Published Papers (8 papers)

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Research

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13 pages, 1147 KB

Open AccessArticle

Intraoperative Extracorporeal Life Support for Bilateral Sequential Lung Transplantation

by Tomislav Kopjar, Feda Dzubur, Dorian Hirsl, Goran Glodic, Goran Madzarac, Mislav Planinc, Jasna Spicek Macan, Zeljko Colak, Hrvoje Gasparovic and Miroslav Samarzija

J. Clin. Med. 2025, 14(23), 8315; https://doi.org/10.3390/jcm14238315 - 23 Nov 2025

Viewed by 366

Abstract

Background/Objectives: The use of intraoperative venoarterial extracorporeal life support (VA ECLS) has traditionally been used to support unstable patients undergoing complex lung transplantation. More evidence is emerging that the use of intraoperative VA ECLS may be beneficial for all patients undergoing lung transplantation. The aim of this study was to report the safety and feasibility of lung transplantation with the routine use of central VA ECLS. Methods: In this single-center retrospective observational study, all consecutive patients undergoing lung transplantation from April 2021 until September 2025 were included. Early outcomes and the incidence of primary graft dysfunction were evaluated with the International Society for Heart and Lung Transplantation criteria at 72 h after transplantation. Survival and chronic lung allograft dysfunction (CLAD)-free survival were reported with Kaplan–Meier estimates and 95% confidence intervals (CIs). Results: During the study period, 35 patients were successfully transplanted with the aid of central VA ECLS. There were no complications associated with intraoperative ECLS. One revision surgery was performed for immediate postoperative bleeding, and one for bronchial anastomosis air leak. Operative mortality occurred in three patients (8.6%). The median in-hospital stay was 30 (25–43) days. Severe primary graft dysfunction at 72 h was observed in four (11.4%) patients. Survival and CLAD-free survival at 1-, 3-, and 5-years following surgery were 85% (95% CI [74–98]), 74% (95% CI [59–92]), 67% (95% CI [28–82]), and 82% (95% CI [70–96]), 52% (95% CI [37–74]), 36% (95% CI [11–59]), respectively. Conclusions: Lung transplantation can safely be performed with the aid of central VA ECLS, with a low rate of primary graft dysfunction and favorable long-term outcomes. Further follow-up studies and greater experience are needed to make inferences on the long-term outcomes. This technique is relatively recent and evolving, representing an innovative intersection of advanced supportive technology with transplant surgery, potentially broadening indications and improving success rates. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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9 pages, 1212 KB

Open AccessArticle

20-Year Efficacy of Endoscopic Thoracic Sympathectomy for Primary Hyperhidrosis: A Cohort Study

by Anna Ureña, Leandro Grando, Lluisa Rodriguez-Gussinyer, Ivan Macía, Francisco Rivas, Nestor Iván Quiroga, Camilo Moreno, Xavier Michavilla and Ricard Ramos

J. Clin. Med. 2025, 14(14), 4831; https://doi.org/10.3390/jcm14144831 - 8 Jul 2025

Viewed by 3598

Abstract

Background: Primary focal hyperhidrosis, characterized by excessive sweating primarily affecting the hands and axillae, can significantly impact quality of life. Bilateral thoracic sympathectomy is the gold standard treatment, providing permanent resolution of palmar hyperhidrosis. Most studies evaluating outcomes and patient satisfaction after sympathectomy focus on short- to medium-term follow-up, typically up to 5 years. This study aimed to assess anxiety, satisfaction, and sweat redistribution 20 years after bilateral endoscopic thoracic sympathectomy. Methods: Between January 2002 and December 2003, 106 patients with primary hyperhidrosis underwent bilateral endoscopic thoracic sympathectomy targeting ganglia T2–T3 at our center. The patients were contacted via telephone in 2023 and asked to complete the same survey they had filled out preoperatively and 12 months postoperatively. The survey evaluated sweat redistribution, anxiety, hyperhidrosis-related symptoms, and satisfaction. Anxiety, satisfaction, and perceived sweating were rated using a 5-point visual analog scale (VAS) ranging from 0 (unsatisfied/no symptoms) to 4 (very satisfied/severe symptoms). Results: Of the 106 eligible patients, 24 (22.6%) completed the survey. Most reported persistent anhidrosis (palmar or palmar–axillary) 20 years post-surgery. The survey results remained consistent with those at the 1-year follow-up. Significant sweat redistribution to the abdomen and back was observed. Patient satisfaction remained high, with no significant differences between the 1-year and 20-year assessments. Anxiety significantly decreased compared to preoperative levels (p < 0.001). Conclusions: Bilateral endoscopic thoracic sympathectomy is an effective long-term treatment for reducing excessive sweating. Patient satisfaction remains high over time, despite the persistence of compensatory sweating. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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12 pages, 1636 KB

Open AccessArticle

Volume Change Measurements of the Heart and Lungs After Pectus Excavatum Repair

by Gongmin Rim, Kwanyong Hyun and Hyung Joo Park

J. Clin. Med. 2025, 14(12), 4250; https://doi.org/10.3390/jcm14124250 - 15 Jun 2025

Cited by 1 | Viewed by 1155

Abstract

Background/Objectives: The primary objective of PE repair is to relieve compression exerted on the cardiac and pulmonary structures and enhance the thoracic cavity volume. However, the number of volumetric studies of the thoracic cavity, including the heart and lung volumes, is scarce. This study seeks to systematically evaluate the volumetric changes in these structures to assess the physiological impact obtained by PE repair. Methods: A retrospective analysis was conducted on 63 patients who underwent PE repair using the XI bar technique from April 2023 to February 2024. Volumetric changes were measured preoperatively and postoperatively using SYNAPSE 3D imaging software (Version 4.6, Fujifilm, Tokyo, Japan). Cardiac and pulmonary volumes were quantified, and CT indexes (Haller index, Depression index) were assessed. Complication rates, reoperation rates, and length of hospital stay were also analyzed. Results: The mean cardiac volume increased significantly from 458.25 mL preoperatively to 499.13 mL postoperatively (p = 0.018), showing an 8.9% increase. Pulmonary volumes, however, showed no statistically significant change, remaining stable at approximately 4371.31 mL preoperatively and 4266.87 mL postoperatively (p = 0.57). Conclusions: Repairing PE markedly enhances cardiac volume, emphasizing its importance in relieving mediastinal compression. Pulmonary volumes remain largely unaffected, suggesting that PE primarily impacts cardiac structures. Our approach to the volumetric measurements provides valuable insights into the physiological outcomes of chest wall remodeling and is considered to be a good modality for future studies to enhance our understanding of the functional benefits of PE repair. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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12 pages, 1054 KB

Open AccessArticle

Long-Term Results of Segmentectomy vs. Lobectomy for c-Stage IA Lung Cancer: A Real-Life Study with a Propensity Score Analysis Based on a National Cohort

by Iker Lopez, Borja Aguinagalde, Juan A. Ferrer-Bonsoms, Laura Sánchez, Fernando Ascanio, Julio Sesma, José Luis Recuero, Arantza Fernandez-Monge, Jon A. Lizarbe and Raul Embun

J. Clin. Med. 2025, 14(7), 2267; https://doi.org/10.3390/jcm14072267 - 26 Mar 2025

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Abstract

Background/Objectives: The objective was to compare the results of segmentectomy and lobectomy in the treatment of c-stage IA lung cancer in terms of tumor recurrence and 5-year survival. Methods: An observational study was performed using 3533 patients included in the registry of the Spanish VATS Group (GEVATS) of the Spanish Society of Thoracic Surgery (SECT) between 2016 and 2018. A total of 1004 lobectomies and 83 segmentectomies in c-stage IA were selected. Two comparable groups were selected through 2:1 propensity score matching with patient-, tumor- and surgery-related variables, leaving 166 lobectomies and 83 segmentectomies. Tumor recurrence was analyzed by Fisher’s test and overall, cancer-specific, recurrence-free and disease-free survival by Kaplan-Meier and Log-rank tests. Results: Overall recurrence was 23.7% in both groups, with a predominance of locoregional recurrence in segmentectomy (16.2% vs. 11.2%) and distant recurrence in lobectomy (12.5% vs. 7.5%). There was no difference between the two groups in any of the survival types. Overall survival at 5 years was 73.5% (95% CI: 65.5–82.4%) in the lobectomy group vs. 73.1% (95% CI: 60.1–88.9%) in the segmentectomy group. Conclusions: Anatomic segmentectomy may be a valid option in the treatment of c-stage IA lung cancer since the recurrence and long-term survival outcomes compared to lobectomy are equivalent. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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11 pages, 208 KB

Open AccessEditor’s ChoiceArticle

Utility of Artificial Intelligence for Decision Making in Thoracic Multidisciplinary Tumor Boards

by Jon Zabaleta, Borja Aguinagalde, Iker Lopez, Arantza Fernandez-Monge, Jon A. Lizarbe, Maria Mainer, Juan A. Ferrer-Bonsoms and Mateo de Assas

J. Clin. Med. 2025, 14(2), 399; https://doi.org/10.3390/jcm14020399 - 10 Jan 2025

Cited by 7 | Viewed by 2589

Abstract

Background/Objectives: The aim of this study was to analyze whether the implementation of artificial intelligence (AI), specifically the Natural Language Processing (NLP) branch developed by OpenAI, could help a thoracic multidisciplinary tumor board (MTB) make decisions if provided with all of the patient data presented to the committee and supported by accepted clinical practice guidelines. Methods: This is a retrospective comparative study. The inclusion criteria were defined as all patients who presented at the thoracic MTB with a suspicious or first diagnosis of non-small-cell lung cancer between January 2023 and June 2023. Intervention: GPT 3.5 turbo chat was used, providing the clinical case summary presented in committee proceedings and the latest SEPAR lung cancer treatment guidelines. The application was asked to issue one of the following recommendations: follow-up, surgery, chemotherapy, radiotherapy, or chemoradiotherapy. Statistical analysis: A concordance analysis was performed by measuring the Kappa coefficient to evaluate the consistency between the results of the AI and the committee’s decision. Results: Fifty-two patients were included in the study. The AI had an overall concordance of 76%, with a Kappa index of 0.59 and a consistency and replicability of 92.3% for the patients in whom it recommended surgery (after repeating the cases four times). Conclusions: AI is an interesting tool which could help in decision making in MTBs. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

13 pages, 5243 KB

Open AccessArticle

Improved Composite Hydrogel for Bioengineered Tracheal Graft Demonstrates Effective Early Angiogenesis

by Russell Seth Martins, Joanna Weber, Lauren Drake, M. Jawad Latif, Kostantinos Poulikidis, Syed Shahzad Razi, Jeffrey Luo and Faiz Y. Bhora

J. Clin. Med. 2024, 13(17), 5148; https://doi.org/10.3390/jcm13175148 - 30 Aug 2024

Cited by 1 | Viewed by 1768

Abstract

Background/Objectives: Collagen–agarose hydrogel blends currently used in tracheal graft bioengineering contain relatively high concentrations of collagen to withstand mechanical stresses associated with native trachea function (e.g., breathing). Unfortunately, the high collagen content restricts effective cell infiltration into the hydrogel. In this study, we created an improved hydrogel blend with lower concentrations of collagen (<5 mg/mL) and characterized its capacity for fibroblast invasion and angiogenesis. Methods: Four collagen–agarose hydrogel blends were created: 1 mg/mL type 1 collagen (T1C) and 0.25% agarose, 1 mg/mL T1C and 0.125% agarose, 2 mg/mL T1C and 0.25% agarose, and 2 mg/mL T1C and 0.125% agarose. The hydrogel surface was seeded with fibroblasts, while both endothelial cells and fibroblasts (3:1 ratio) were mixed within the hydrogel matrix. We assessed early angiogenesis by observing fibroblast migration and endothelial cell morphology (elongation and branching) at 7 days. In addition, we performed immunostaining for alpha-smooth muscle actin (aSMA) and explored the gene expression of various angiogenic markers (including vascular endothelial growth factor; VEGF). Results: Gels with lower agarose concentrations (0.125%) with 1 or 2 mg/mL T1C were more effective in allowing early attachment and migration of surface-applied fibroblasts compared to gels with higher (0.25%) agarose concentrations. The low-agarose gels also allowed cells to quickly adopt a spread morphology and self-assemble into elongated structures indicative of early angiogenesis, while demonstrating positive immunostaining for aSMA and increased gene expression of VEGF by day 7. Conclusions: Hydrogel blends with collagen and low agarose concentrations may be effective in allowing early cellular infiltration and angiogenesis, making such gels a suitable cell substrate for use in the development of composite bioengineered tracheal grafts. The collagen–agarose hydrogel blend is meant to be cast around a three-dimensional (3D) printed polycaprolactone support structure and wrapped in porcine small intestine submucosa ECM to create an off-the-shelf bioengineered tracheal implant. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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Review

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16 pages, 290 KB

Open AccessReview

Robotic-Assisted Thoracoscopic Surgery Versus Video-Assisted Thoracoscopic Surgery: Which Is the Preferred Approach for Early-Stage NSCLC?

by Nikolaos Syrigos, Eleni Fyta, Georgios Goumas, Ioannis P. Trontzas, Ioannis Vathiotis, Emmanouil Panagiotou, Nikolaos I. Nikiteas, Elias Kotteas and Dimitrios Dimitroulis

J. Clin. Med. 2025, 14(9), 3032; https://doi.org/10.3390/jcm14093032 - 28 Apr 2025

Cited by 1 | Viewed by 1692

Abstract

Lung cancer is the leading cause of cancer-related mortality among both men and women worldwide, underscoring the need for an effective treatment strategy. For early-stage non-small cell lung cancer [NSCLC], surgical resection is the standard treatment. Robotic-assisted thoracic surgery [RATS] and video-assisted thoracic surgery [VATS] are better than open thoracotomy because they are less invasive. Recent lung cancer screening programs are detecting NSCLC at earlier stages, which is expected to result in an increase in the number of NSCLC surgeries as early-stage cases are diagnosed. A limited number of randomized controlled trials have compared RATS and VATS in operable NSCLC. We conducted a literature review to summarize the available evidence on these two surgical techniques. The purpose of this study is to compare the intraoperative and postoperative outcomes of RATS and VATS in early-stage NSCLC patients. RATS shows lower conversion rates to thoracotomy (6.3% vs. 13.1% p < 0.01) and more thorough lymph node dissection than VATS (e.g., 7.5 vs. 5.6 stations, p < 0.001). However, RATS is linked to considerably higher costs (USD 22,582 vs. USD 17,874, p < 0.05) and longer operative times (median 241.7 vs. 214.4 min, p = 0.06). The two techniques exhibited minimal differences in postoperative complications and pain, while RATS patients experienced shortened hospital stays (4–5 vs. 5–6 days, p < 0.006). While the accuracy of staging and treatment planning is improved by the improved lymph node retrieval in RATS, the long-term survival rate is still uncertain. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

Other

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15 pages, 396 KB

Open AccessPerspective

From Awake to Minimalist Spontaneous Ventilation Thoracoscopic Mediastinum Surgery: How Far Are We?

by Alexandro Patirelis, Vincenzo Ambrogi and Eugenio Pompeo

J. Clin. Med. 2025, 14(23), 8396; https://doi.org/10.3390/jcm14238396 - 26 Nov 2025

Viewed by 387

Abstract

Spontaneous ventilation (SV) video-assisted thoracic surgery (VATS) is aimed at offering less invasive alternatives to equivalent procedures under tracheal intubation with mechanical ventilation (MV) and its benefits have shown encouraging results in lung surgery. In addition, there is also growing interest in SV-VATS in mediastinum surgery. The rationale of SV in simpler mediastinum procedures is that MV anesthesia could be considered avoidable if SV anesthesia protocols could provide similar or even better results. On the other hand, for other indications involving more delicate patient subgroups, SV-VATS is aimed at offering a more rapid recovery with less anesthesia-related risks of cardio-respiratory complications. Based on encouraging initial results, SV is also being proposed for more demanding surgical procedures, including tracheal resection and esophagectomy. However, SV mediastinum surgery also implies contraindications, potential disadvantages and peculiar physiopathologic issues which must be clearly acknowledged. This perspective is aimed at providing a critical overview of the current knowledge about SV for mediastinum surgery, with a particular emphasis on the last 10 years of data about thymectomy, biopsy of mediastinal masses, thoracic sympathectomy, tracheal resection, pericardial window and esophagectomy. Full article

(This article belongs to the Special Issue Thoracic Surgery: Current Challenges and Future Perspectives)

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