Stefano Bongiolatti

Carinal and tracheal sleeve resections represent the most technically demanding procedures in thoracic surgery, reserved for a highly selected subset of patients with primary tracheal tumours or bronchogenic carcinomas involving the tracheobronchial angle. Despite advances in anaesthetic management and surgical technique, these operations carry substantial perioperative risk; reported mortality rates range from 3% to 20% even in high-volume centres. This narrative review appraises current evidence on tracheal and carinal resection for oncological disease, focusing on surgical technique, anaesthetic strategies, including the expanding role of veno-venous extracorporeal membrane oxygenation (VV-ECMO), and oncological outcomes, and positions these findings against several closely related reviews published in 2025–2026. The principles of tracheal surgery are reviewed: tension-free anastomosis, preservation of segmental blood supply, and suture technique. We also present our institutional experience with complex carinal resections, including three left tracheal sleeve pneumonectomies performed through median sternotomy without cardiopulmonary bypass and other cases of major tracheobronchial surgery. Our institutional experience illustrates that, in expert hands, these operations can offer favourable long-term survival, particularly for adenoid cystic carcinoma and for patients with N0–N1 disease. VV-ECMO and apnoeic oxygenation may facilitate resections that would otherwise be technically prohibitive and have shown encouraging safety in selected expert-centre series, although this evidence remains limited to small, non-comparative cohorts.

Objectives: Occult visceral pleural invasion (VPI) may upstage cT1N0M0 non-small cell lung cancer (NSCLC) to pT2aN0M0. We compared perioperative and oncological outcomes after segmentectomy and lobectomy in this setting. Methods: This multicentre retrospective study included cT1N0M0 NSCLC patients treated with minimally invasive segmentectomy or lobectomy who were subsequently upstaged to pT2aN0M0 because of VPI. Propensity-score matching (PSM) (1:1) was performed. Perioperative and oncological outcomes were compared. Exploratory and sensitivity analyses evaluated tumours ≤20 mm and patients who did not receive adjuvant therapy. Results: Among 448 patients, 104 underwent segmentectomy and 344 underwent lobectomy. After PSM, 87 matched pairs were analysed. Segmentectomy was associated with shorter operative time, lower postoperative morbidity, and shorter hospital stay. No significant differences were observed in disease-free survival (DFS) (P = .387), overall survival (OS) (P = .075), or cancer-specific survival (CSS) (P = .388). Multivariable analysis identified adjuvant therapy and age as independent predictors of DFS and OS, respectively, whereas the extent of resection was not independently associated with survival. In patients with a preoperative computed tomography (CT) total tumour diameter ≤20 mm, segmentectomy was associated with a higher rate of local recurrence (13.8 vs 2.0%, P = .037) and worse adjusted DFS and OS, despite no significant differences in Kaplan-Meier survival. Conclusions: In patients with cT1N0M0 NSCLC upstaged to pT2aN0M0 because of occult VPI, segmentectomy was associated with lower postoperative morbidity, with no significant differences in oncological outcomes in the overall matched cohort. Exploratory findings in patients with a preoperative CT total tumour diameter ≤20 mm suggest a higher risk of local recurrence and worse adjusted DFS and OS after segmentectomy, warranting further validation.

Objective: Minimally invasive lung resections are the standard treatment of early stage non‐small‐cell lung cancer (NSCLC) and robot‐assisted surgery has gained popularity. This study aims to compare the postoperative outcomes, pain scores and opioid consumption among three approaches: uniportal thoracoscopic (uVATS), multiport robot‐assisted (mRATS) and uniportal robot‐assisted (uRATS). Methods: We retrospectively analysed patients undergoing major lung resections for NSCLC via minimally invasive approaches by a single surgeon between 2021 2025. Results: In the study period, 109 uVATS, 40 mRATS and 19 uRATS surgeries were performed with similar outcomes, except for a longer operative time for uRATS procedures ( p < 0.01). Pain scores were comparable, but the percentage of patients requiring morphine and the median total intravenous morphine equivalents were lower in the single‐port techniques in comparison with mRATS ( p < 0.01 and p = 0.046). Conclusions: Although post‐operative pain was comparable across approaches, the uRATS technique seems associated with reduced opioid and morphine requirements.

Objectives: The surgical treatment of multiple synchronous bilateral primary lung cancer (mSBPLC) showed promising results and the aims of this retrospective study were to assess the oncologic outcomes and the presence of risk factors of worse survival. Methods: Patients underwent radical (all lesions removed) lung resection for mSBPLC from 2017 to 2024 were included. Exclusion criteria: patients unfit for bilateral surgery, pneumonectomy, multifocal ground-glass opacities, clinical stage IIIA or more, and preoperative treatment. Overall and disease-free survival (DFS) analyses were conducted with the Kaplan-Meier method and log-rank test, Cox-regression analysis was used to identify the predictors of worse survival. Results: During the study period, 64 patients were screened for the presence of bilateral lung nodules, 45 patients (median age 69 years) were operated for mSBPLC and during the follow-up (median 34 months) we observed 11 deaths and 15 cancer recurrence. In the 80% of patients the main cancer was solid, contralateral was a part-solid in 20%, or pure ground-glass opacity in 20%. Adenocarcinoma was present in 77.8% at first surgery and in 80% at the second. Spread Through the Air Spaces (STAS) was present in 17.8%. The 5-year overall and DFS rate were 77% (median 86 months, 95% CI 72.4-99.5-) and 57% (median 69 months, 95% 32-105.9), respectively. Comparing survivals among patients with and without STAS, we had an overall survival of 0% vs 85% (86 vs 29 months, P < .01) and a DFS of 0% vs 63% (69 vs 9 months, P < .01). The multivariable analysis demonstrated STAS as significant predictor of worse overall (HR 7.08, P = .02) and DFS (HR 5.63, P = .017). Conclusions: Taking into account the small and highly selected study population, staged bilateral surgery could be considered safe and oncologically adequate, showing the association between the presence of STAS and unfavourable long-term outcomes.

Background: Major airway injuries, regardless of whether their aetiology is traumatic or iatrogenic, are rare but potentially fatal. In selected cases, surgery plays a key role; however, it has to be performed by highly experienced professionals in emergency settings. Methods: We reviewed all surgical procedures involving the trachea which were performed at our institution in the last 5 years (365 procedures). We report here our experiences with major airway injuries, both traumatic and iatrogenic (19 procedures). All patients, including individuals from within our hospital and from other peripheral centres, were treated in an emergency setting within 12 h of correct diagnosis. Results: The location and extent of tracheal lesions can be different in every patient. After a proper evaluation with CT scan and bronchoscopy, we approached all our cases of tracheal injuries with a cervicotomy, using, in some selected cases, an endoscopic camera to better visualise lesions that involved the carina. However, in extremely severe cases, such as one we report here, where multiple repair attempts fail and tissue viability is compromised, demolitive surgery by means of posterolateral thoracotomy may represent the only remaining therapeutic option. Conclusions: Surgery on tracheal injuries is complex, highly specialised, and time-dependent. In selected cases, it has to be performed quickly by highly qualified professionals after proper evaluation in an emergency setting. Every airway injury differs in its location, extent, aetiology, and clinical presentation, and there is no unanimous consensus on standardising treatment. Only high-volume centres with highly experienced professionals can guarantee correct management of this rare but life-threatening event.

Objective: Minimally invasive anatomic lung resections are the standard for early non‐small‐cell lung cancer, and the robotic approach has gained popularity and the latest frontier is the uniportal robotic (uRATS) approach. The goal of our study is to share our series showing technical details, feasibility and early outcomes. Methods: From December 2024, we started the uRATS programme for selected patients. Continuous and dichotomous variables were recorded about surgery and the perioperative period. Non‐parametric tests were used to compare the data between uRATS and contemporary patients treated with robotic multiport RATS. Results: In 4 months we performed two segmentectomies and five Lobectomy through uRATS, while one patient was converted due to incomplete fissure. No severe perioperative complications occurred and in the comparison with the multiport approach, no significant differences in operative time, conversions and complications were observed. Conclusions: The Uniportal RATS approach was safe and feasible with adequate surgical and oncologic post‐operative results.

Diaphragmatic eventration is a condition characterized by the abnormal elevation of a hemidiaphragm, resulting in significant respiratory symptoms such as dyspnea, exercise intolerance, and impaired ventilation, due to a mass effect by raised abdominal organs and to the inability of the diaphragm to promote adequate expansion of the chest and subsequent poor ventilation and impaired gas exchange. In symptomatic patients, diaphragmatic plication is a well-established surgical treatment aimed at improving respiratory function by reducing dysfunctional diaphragm excursion and promoting greater lung expansion. This study investigates the use of robot-assisted thoracic surgery (RATS) for diaphragmatic plication and application of absorbable mesh to reduce the risk and prevent recurrence of diaphragm re-elevation. The procedure is performed via a transthoracic approach using the Da Vinci Surgical System, which provides enhanced precision, meticulous tissue handling and accurate suture placement, allowing difficult maneuvers such as mesh placement and probably with improved early and long-term outcomes. The addition of a Vicryl mesh further supports the diaphragm and helps reduce the risk of postoperative complications such as recurrence of diaphragm elevation. This robot-assisted approach has been shown to reduce postoperative pain, shorten hospital stays, and significantly enhance patient quality of life by addressing symptoms like dyspnea and fatigue. This study highlights the safety, efficacy, and minimal invasiveness of robot-assisted diaphragmatic plication as a treatment option for diaphragmatic dysfunction.

Background: Lung segmentectomy is widely used to treat early-stage non-small cell lung cancer (NSCLC), but the risk of local recurrence in the ipsilateral lobe is increased and the surgical treatment of the local recurrence could be a real challenge. The aim of this study is to report our experience in a consecutive series of patients undergoing completion lobectomy (CL) after thoracoscopic segmentectomy. Methods: We retrospectively reviewed all the medical charts of the patients who underwent thoracoscopic segmentectomy for early-stage NSCLC (cIA) between January 2015 and December 2023, focusing on patients who had NSCLC recurrence in the ipsilateral lobe treated with CL. Results: Among the 263 segmentectomies performed, 13 patients (4.9%) experienced local recurrence in the ipsilateral remaining lobe, of whom 9 (3.4%) underwent CL, including 5 in the left upper lobe, with a median interval of 31 months between procedures. All patients underwent CL through thoracotomy with the need of central isolation in 5/9 (55.5%); rupture of the pulmonary artery occurred two patients and vascular sleeve resection was necessary in one. No postoperative deaths were observed, complications occurred in 5/9 patients with major complications, defined as Clavien-Dindo grade >3b, in 2/9 (22.2%) patients. Median hospital stay was 11 days. At the end of follow-up 2 patients had distant recurrence 12 median months after the CL. Conclusions: CL in the left side could be considered a challenging procedure also after minimally invasive segmentectomy and we consider safe to perform CL with thoracotomy due to a scar tissue formation between the bronco-vascular structures leading the need for extensive hilar dissection and central isolation of the pulmonary artery.

Background: Lung adenocarcinoma exhibits heterogeneity among different histological subtypes, with solid and micropapillary subgroups (classified as high-grade) associated with worse prognosis. The aim of this retrospective study was to investigate the impact of high-grade adenocarcinoma on survival in patients undergoing intentional thoracoscopic segmentectomy. Methods: Patients who underwent segmentectomy for clinical-stage IA non-small-cell lung cancer between 2016 and 2023 were reviewed. The adenocarcinoma population was divided and compared based on the presence of high-grade adenocarcinoma >20%, based on the 2021 WHO classification. Survival probabilities were estimated using the Kaplan–Meier method and log-rank test. The Cox proportional hazard regression model was used to test the association between survival and covariates. Results: The adenocarcinoma population included 216 patients, with high-grade adenocarcinoma >20% in 47 (21.7%). A consolidation-to-tumor ratio >0.8 was more frequent in the high-grade adenocarcinoma population. Survival analyses showed that overall (5-year OS rate 57% vs. 90%, p < 0.01), cancer-specific (5-year CSS rate 66% vs. 91%, p < 0.01) and disease-free survival (5-year DFS rate 53% vs. 75%, p < 0.01) were significantly worse in patients with high-grade adenocarcinoma. No significant differences in overall and disease-free survival were observed when compared to a contemporary cohort of lobectomy patients. Recurrence and high-grade pattern (HR 3.26, 95%CI 1.4–7.6, p < 0.01) were significant risk factors for reduced overall survival, whereas high-grade adenocarcinoma >20% (HR 2.43, 95%CI 1.25–4.71, p < 0.01) and a consolidation-to-tumor ratio >0.8 were risk factors for reduced disease-free survival. Conclusions: The prognosis of high-grade adenocarcinoma is sub-optimal even in radically treated early-stage patients, and close monitoring and a complete bio-molecular assessment should be advisable in light of a multimodal adjuvant approach. However, the different subtypes of adenocarcinoma could be inserted as a staging parameter in future international staging systems.

Background: The surgical treatment of concomitant lung cancer in patients with idiopathic pulmonary fibrosis is challenging due to the risk of life-threatening complications such as acute exacerbation development in the perioperative period. Few studies have investigated the role of anti-fibrotic drugs in this setting. The aim of this multicenter retrospective study was to evaluate the incidence of acute exacerbation, according to Collard, after lung resection in patients affected by concomitant idiopathic pulmonary fibrosis and lung cancer who were or were not on antifibrotic treatment. Secondary outcomes included: 30 and 90-day mortality and an estimation of overall and disease-free survival. Material and Methods: The study population consisted of patients affected by idiopathic pulmonary fibrosis who received curative-intent lung surgery in three Italian academic centers between 2015 and 2022. Patients were divided into two groups based on whether they were on perioperative treatment with anti-fibrotic drugs (chronical or prophylactic use) or not. To define predictors of acute exacerbation, univariate and multivariable exact logistic regression analysis were performed. The Kaplan–Meier method with log-rank test was used to estimate survival. Results: During the study period, n = 55 patients underwent lung resection for lung cancer, including 29 patients who were treated with antifibrotic agents. Although the sample size was small and few events were studied, the incidence of acute exacerbation was significantly lower among patient on anti-fibrotic therapy (3.4% vs. 23.1%, p = 0.044); in addition, anti-fibrotic treatment was the strong factor preventing acute exacerbation at the multivariable analysis (OR 0.089, p = 0.038). Post-operative 30- and 90-day mortality rates were not significantly lower in the anti-fibrotic treatment group (0% and 0% vs. 7.7% and 11.5%, p = 0.21 and p = 0.099, respectively). Overall and disease-free survival rates were similar. Conclusions: Considering the limitations of this retrospective study with a small sample size, anti-fibrotic perioperative treatment was associated with reduced incidence of acute exacerbation. Based on these real-world data, this pathway could be proposed as a prophylactic treatment in patients with concomitant idiopathic pulmonary fibrosis and cancer undergoing lung resection.