The changing landscape of general thoracic surgery: paradigm shifts in airway management, chest wall reconstruction, and advanced oncology
Fabio Maroso, Giuseppe Casablanca, Angelo Carretta, Fabrizio Grignani, Giuseppe Agneta, Marco Casaccia, Paolo Scanagatta, Mario Di Stasio, Francesco Givigliano, Giovanni Muriana, Carlo Curcio, Enrico Potenza, Massimo Jaus, Gian Luca Pariscenti, Enrico Melis, Giorgio Carlo Ginesu, Emanuele Russo, Guglielmo Monaco, Cosimo Lequaglie, Maurizio Nicolosi, Lucio Cagini, Edoardo Mercadante, Marco Taurchini, Massimiliano Paci, Rosario Salvi, Salvatore Strano, Francesco Facciolo, Giuseppe Cardillo, Giulio Melloni, Domenico Galetta, Gianluca Guggino, Francesco Petrella, Stefano Meda, Federico Raveglia, Manuela Cuoghi, Lavinia Amato, Silvia Tedesco, Francesca Sardo, Alberto Terminella, Manuela Girina, Francesca Re, Alberto Molteni,Background:
Thoracic surgery is evolving through minimally invasive technologies, robotic platforms, multimodal oncological treatments, and integration between surgery, systemic therapies, and molecular characterization. Contemporary decision-making balances oncological radicality, functional preservation, technical feasibility, and multidisciplinary management.
Methods:
This narrative review derives from the Thoracic Surgery session of the 44th National Congress of the Italian Association of Hospital Surgeons (ACOI), Palermo, Italy (24–27 May 2026). It followed the standardized artificial intelligence-assisted, clinician-supervised methodology described by Molteni et al. The complete audiovisual recording and original presentations constituted the primary source material. Individual clinical cases and selected electronic presentations were excluded.
Results:
Endoscopic treatment remains the preferred first-line approach for benign airway disease, whereas tracheal resection is reserved for selected patients. Pleuro-parenchymal infections, empyema, chest-wall reconstruction, and thoracic emergencies require individualized multidisciplinary management. Complete thymectomy achieving R0 resection remains the fundamental oncological principle, while minimally invasive and robotic approaches are appropriate only if oncological radicality is preserved. Functional esophageal surgery emphasizes physiological assessment and tailored minimally invasive treatment. In thoracic oncology, perioperative immune checkpoint inhibition is reshaping treatment paradigms, and resectability increasingly incorporates pathological response, circulating tumor DNA, and tumor biology alongside anatomical criteria. The optimal extent of pulmonary resection in early-stage lung cancer remains under investigation.
Conclusions:
Contemporary thoracic surgery is defined by multidisciplinary decision-making, individualized patient selection, preservation of oncological radicality, and concentration of complex procedures in high-volume centers. Integration of surgery, systemic therapies, molecular biomarkers, and immunotherapy is redefining resectability as a dynamic biological concept rather than a purely anatomical condition.