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Thoracic Surgery: State of the Art and Future Directions
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Thoracic Surgery: State of the Art 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: 20 March 2026 | Viewed by 4387

Special Issue Editors

Prof. Dr. Ugo Cioffi

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Guest Editor
Department of Surgery, University of Milan, 20122 Milano, Italy
Interests: training in surgery; AI in surgery; lung cancer
Dr. Marco Scarci

E-Mail Website
Guest Editor
Department of Thoracic Surgery, Imperial College NHS Healthcare Trust, London W12 0HS, UK
Interests: training in surgery; AI in surgery; lung cancer
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

In this Special Issue, we aim to bring together a prestigious panel of experts to cover all aspects of thoracic surgery practice, encompassing both benign and malignant pathologies.

Our experts will share their insight into the latest research into thoracic surgery, addressing areas of uncertainty and highlighting the latest evidence-based practice.

This Special Issue aims to be seen as an annual update for busy thoracic surgeons, residents, and fellows who do not attend meetings regularly.

The articles are structured in an easy-to-follow style and give practical “take-home messages” to guide and improve current surgical practice.

We hope you enjoy reading this Special Issue.

Prof. Dr. Ugo Cioffi
Dr. Marco Scarci
Guest Editors

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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

  • thoracic surgery
  • lung surgery
  • lung cancer
  • rib fractures
  • lung disease
  • pectus excavatum

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Published Papers (5 papers)

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Research

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21 pages, 2066 KB  
Article
Evaluation of Pulmonary Blood Flow, Right Atrium, Right Ventricle, and Pulmonary Artery in Patients After Pneumonectomy
by Michał Stępkowski, Małgorzata Edyta Wojtyś, Norbert Wójcik, Krzysztof Safranow, Jarosław Pieróg, Dawid Kordykiewicz, Jacek Szulc, Tadeusz Sulikowski, Konrad Jarosz, Tomasz Grodzki and Janusz Wójcik
J. Clin. Med. 2025, 14(19), 6793; https://doi.org/10.3390/jcm14196793 - 25 Sep 2025
Cited by 1 | Viewed by 630
Abstract
Background/Objectives: After pneumonectomy, the right ventricular stroke volume is pumped into pulmonary vessels whose volume has been reduced by approximately 50%. To sustain conditions for pulmonary flow, the flow reserve is increased in the remaining lung, which is conducive to the development [...] Read more.
Background/Objectives: After pneumonectomy, the right ventricular stroke volume is pumped into pulmonary vessels whose volume has been reduced by approximately 50%. To sustain conditions for pulmonary flow, the flow reserve is increased in the remaining lung, which is conducive to the development of pulmonary hypertension symptoms. This study sought to examine pulmonary flow in one lung and the size of the right atrium (RA), right ventricle (RV) and pulmonary artery (PA) in patients who had undergone pneumonectomy and to establish the influence of time since pneumonectomy on these parameters, as well as their potential mutual dependencies. Methods: The retrospective analysis included 34 patients who had undergone pneumonectomy. Pulmonary flow was measured by means of perfusion scintigraphy. The diameters of the RA, RV and PA were evaluated based on computed tomography with contrast. Results: We observed complete or near-complete utilization of flow reserve in 38.2% (13/34) of patients, enlarged transversal and longitudinal dimensions of the RA in 17.6% (6/34) and 32.3% (11/34) of patients, respectively, and enlarged transversal and longitudinal dimension of the RV in 67.6% (23/34) and 44.1% (15/34) of patients, respectively. Dilatation of the PA was discovered in 23.5% (8/34) to 26.5% (9/34) of patients, as well as the presence of an extensive complex of radiographic features of pulmonary hypertension (PH) syndrome in 23.5% (8/34) of cases. Conclusions: Radiological features of PH were present in a significant number of patients. These features developed at varying rates but were present in all patients followed >10 years after the procedure. Full article
(This article belongs to the Special Issue Thoracic Surgery: State of the Art and Future Directions)
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10 pages, 840 KB  
Article
First 50 Cases with the ION Robotic-Assisted Navigational Bronchoscopy System in Routine Clinical Use in Germany: The Bonn Experience
by Donatas Zalepugas, Dirk Skowasch, Philipp Feodorovici, Benedetta Bedetti, Philipp Schnorr, Carmen Pizarro, Verena Tischler, Jan Arensmeyer, Daniel Kuetting, Joachim Schmidt and Hruy Menghesha
J. Clin. Med. 2025, 14(17), 6155; https://doi.org/10.3390/jcm14176155 - 31 Aug 2025
Cited by 1 | Viewed by 1324
Abstract
Background: The diagnostic work-up of small peripheral pulmonary nodules (PPNs) is becoming increasingly important, especially in light of the upcoming lung cancer screening programs and recommendations in practice. The systematic clinical introduction of the ION robotic-assisted navigational bronchoscopy (RNB) system represents a significant [...] Read more.
Background: The diagnostic work-up of small peripheral pulmonary nodules (PPNs) is becoming increasingly important, especially in light of the upcoming lung cancer screening programs and recommendations in practice. The systematic clinical introduction of the ION robotic-assisted navigational bronchoscopy (RNB) system represents a significant innovation in Germany, whereas clinical experience in the United States has already yielded promising results. The objective of this study is to present the outcomes of the first 50 patients examined with the ION system at our institutions. Materials and Methods: This is a retrospective, single-center analysis. We included the first 50 consecutive patients who underwent diagnostic evaluation of pulmonary nodules using the ION-RNB system, either in the Department of Thoracic Surgery or the Department of Pulmonology. Results: A total of 50 patients were evaluated, including 24 from the Department of Thoracic Surgery and 26 from the Department of Pulmonology. The pulmonary nodules were found in the peripheral third of the lung in 74% of cases, in the middle third in 18% of cases, and in the central third in 8% of cases. The mean lesion size was 1.64 cm (±0.91 cm). In all, 84% of the nodules were solid, 4% were subsolid, and 12% presented as ground-glass opacities (GGOs). Cone beam computed tomography (CBCT) was used to confirm tool-in-lesion position in 68% of cases compared to C-arm fluoroscopy in 32%. Additionally, radial endobronchial ultrasound (rEBUS) was applied in 30% of procedures. The overall diagnostic yield, independent of imaging modality or histological processing method, was 78%. When CBCT and formalin-fixed paraffin-embedded (FFPE) histological analysis were utilized, the diagnostic yield exceeded 90%. Conclusions: Initial clinical experience with the ION-RNB system in Germany shows encouraging results. The high diagnostic accuracy underlines the system’s potential for evaluating peripheral pulmonary lesions precisely. The use of advanced imaging techniques, particularly CBCT, and the choice of histopathological processing methods are critical variables in optimizing patient-centered diagnostic pathways. Further prospective studies are warranted to assess the long-term clinical utility of robotic-assisted bronchoscopy in diverse clinical settings. Full article
(This article belongs to the Special Issue Thoracic Surgery: State of the Art and Future Directions)
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10 pages, 240 KB  
Article
Does the Use of Oral Nutritional Supplements Influence the Rate of Postoperative Complications After Uniportal Video-Assisted Thoracoscopic Lung Resection?
by Marco Andolfi, Michela Tiberi, Michele Salati, Marina Taus, Nadia Campelli, Francesco Xiumè, Alberto Roncon, Gian Marco Guiducci, Anna Chiara Nanto, Claudia Cola, Loris Angeli Temperoni and Majed Refai
J. Clin. Med. 2025, 14(12), 4226; https://doi.org/10.3390/jcm14124226 - 13 Jun 2025
Viewed by 987
Abstract
Background: The positive effects of oral nutritional supplements (ONS) on postoperative outcomes have been well recognized in several previous studies. However, to date, little data has been available with respect to determining the best immune modulating supplement to use and what its impact [...] Read more.
Background: The positive effects of oral nutritional supplements (ONS) on postoperative outcomes have been well recognized in several previous studies. However, to date, little data has been available with respect to determining the best immune modulating supplement to use and what its impact might be in thoracic surgery. The aim of this study was to evaluate the role of preoperative immune-nutritional supplement intake as predictor of postoperative cardiopulmonary complications (CPCs) in patients undergoing uniportal video-assisted thoracoscopic (uVATS) lung resection. Methods: This is a retrospective, observational study enrolling consecutive patients who underwent uVATS lung resections for cancer from January 2022 to December 2024 in the context of the Enhanced Pathway of Care (EPC) Program. All patients were evaluated by a nutritionist and dietetics team during the preoperative phase. The nutritional protocol consisted of 250 mL ONS rich in arginine, omega-3-fatty acids, and nucleotides to be taken twice a day for 5–7 days before surgery. Results: Four hundred ninety-one patients were enrolled: 277 patients underwent anatomic lung resection and 214 underwent wedge resection (WR). Utilizing the univariate analysis, we found that in patients undergoing anatomic lung resection, not-ONS-intake, high Body Mass Index (BMI), and arrythmia were correlated with a higher CPCs rate compared to the patients without nutritional supplementation (7.2% ONS vs. 15% not-ONS, p = 0.04; BMI 28.4 kg/m2 vs. BMI 26.4 kg/m2, p = 0.03; 31.2% arrythmia vs. 9.4% no-arrythmia, p < 0.01). These correlations, except for BMI, were confirmed after stepwise logistic regression. Alternately, in patients undergoing WR, hypertension and low-FEV1% were associated with a higher CPCs rate (5.1% hypertension vs. 0.4% no-hypertension, p = 0.02; FEV1% 79.7% vs. 95%, p = 0.01). Conclusions: Our results demonstrated that preoperative ONS after uVATS anatomic lung resection, in the context of an EPC program, influences the postoperative period, reducing the CPCs rate. Full article
(This article belongs to the Special Issue Thoracic Surgery: State of the Art and Future Directions)

Other

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10 pages, 3439 KB  
Case Report
Thoracoplasty Without Rib Resection by the Sawamura Technique: A Forgotten Technique for Effective Complex Pleural Empyema Management in a Single-Step
by Kostas Kostopanagiotou, Kostas Papagiannopoulos, Jacek Szulc, Norbert Wójcik and Małgorzata Edyta Wojtyś
J. Clin. Med. 2025, 14(21), 7673; https://doi.org/10.3390/jcm14217673 - 29 Oct 2025
Viewed by 466
Abstract
Treatment for complex pleural empyema often requires thoracoplasty with rib(s) resection to remodel the thoracic cage and obliterate chronic infected pleural cavities. Such procedures are complicated and result in permanent body deformation, which is not acceptable by most adults. Standard decortication often fails [...] Read more.
Treatment for complex pleural empyema often requires thoracoplasty with rib(s) resection to remodel the thoracic cage and obliterate chronic infected pleural cavities. Such procedures are complicated and result in permanent body deformation, which is not acceptable by most adults. Standard decortication often fails as there is residual space for reinfection development, and often necrotizing pneumonia co-exists. Here we describe the surgical management of three complicated adult patients using the modified version of the Sawamura technique which involves debridement and partial decortication followed by ribs stripped of periosteum and surrounding soft tissues, to allow collapse deep into the pleural cavity, thereby obliterating the chronic space in conjunction with partial lung re-expansion. We utilized the serratus muscular flap to repair any bronchial defects due to resected gangrenous parenchyma. No further reoperations were necessary, and no residual effusions were drained. At the 6-month follow-up, these three patients experienced no complications, and their body shapes and functionality were unaltered. This modified Sawamura technique offers an effective single-step treatment while being cosmetically suitable for young adults, and presents an extremely attractive option in countries with limited healthcare resources. Full article
(This article belongs to the Special Issue Thoracic Surgery: State of the Art and Future Directions)
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14 pages, 1025 KB  
Systematic Review
Beyond Mortality: Textbook Outcome as a Novel Quality Metric in Cardiothoracic Surgical Care
by Dimitrios E. Magouliotis, Vasiliki Androutsopoulou, Prokopis-Andreas Zotos, Ugo Cioffi, Fabrizio Minervini, Noah Sicouri, Dimitrios Zacharoulis, Andrew Xanthopoulos and Marco Scarci
J. Clin. Med. 2025, 14(21), 7660; https://doi.org/10.3390/jcm14217660 - 28 Oct 2025
Viewed by 529
Abstract
Objective: Textbook outcome (TO) is a multidimensional composite quality metric that integrates several desirable short-term outcomes into a single measure representing the “ideal” perioperative course. Unlike traditional indicators that focus narrowly on mortality or single complications, TO captures the complexity of cardiothoracic care, [...] Read more.
Objective: Textbook outcome (TO) is a multidimensional composite quality metric that integrates several desirable short-term outcomes into a single measure representing the “ideal” perioperative course. Unlike traditional indicators that focus narrowly on mortality or single complications, TO captures the complexity of cardiothoracic care, encompassing oncologic adequacy, absence of major complications, avoidance of reintervention and readmission, and timely discharge. Methods: In this systematic review, we synthesize evidence on the definition, incidence, determinants, prognostic impact, and limitations of TO across cardiothoracic surgery (lung and esophageal resections, lung transplantation, cardiac surgery, and adult heart transplantation) in accordance with the PRISMA guidelines. Results: Reported achievement rates range from 24% to 66% in thoracic series, 30% after Norwood palliation, 37–45% after adult heart transplantation, and 52% in a contemporary national cohort of lung transplantation, with wide between-center variability. Achieving TO is consistently associated with improved overall and disease-free survival, lower costs, and enhanced benchmarking. Determinants of failure include inadequate lymph node dissection, prolonged operative time, advanced comorbidity, pretransplant organ support, and socioeconomic disadvantage. Heterogeneity of definitions, limited incorporation of patient-reported outcomes, and equity concerns remain barriers to its successful use. Outside transplantation, benchmarking of TO in adult cardiac procedures (e.g., CABG/valve) remains limited and non-standardized. Conclusions: We argue for harmonized, procedure-specific core TO sets aligned with widely available registry fields, integration of equity-sensitive risk adjustment, and prospective validation. TO is poised to become a cornerstone metric of quality assessment and improvement in cardiothoracic surgery. Full article
(This article belongs to the Special Issue Thoracic Surgery: State of the Art and Future Directions)
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