Postoperative pneumonia in the era of minimally-invasive thoracic surgery: a narrative review

background and objective: the last two decades have been marked by a huge revolution in thoracic surgery. the mainstays of this process have been the advent of minimally-invasive approaches, alongside with the implementation fast-track strategies and other quality improvement programs. In this rapidly evolving scenario, occurrence of postoperative pneumonia (POP) after lung resections remains a serious problem, with reported rates varying from 1.5% to 10%. the goal of this study is to review current knowledge and trends in the management of POP in the context of modern era thoracic surgery.methods: a literature search was conducted in order to review the best evidences regarding the following scenarios: ( I) influence of minimally-invasive approaches on POPs incidence; (II) current practice in antibiotic prophylaxis; and ( III) relevance of rehabilitation protocols in the environment of minimally-invasive lung surgery. specific boolean queries were set to this purpose. key content and findings: the majority of studies show that video-assisted thoracic surgery (VATS) approaches are effective at lowering the incidence of POPs and other complications as well, compared to open surgery. however, data interpretation is somewhat affected by the lack of harmonized definition of POPs amongst studies. furthermore, some studies did not include POPs as a primary endpoint, thus resulting underpowered in this regard. operative time, technical proficiency with minimally-invasive surgery, and patient selection can also be important confounding factors. pre- and post-operative rehabilitation may both amplify the benefits of a minimally-invasive approach. on the other hand, current practice in antibiotic prophylaxis is based on studies dating back more than 30 years ago, a fact that reasonably calls for a revision on the light of modern thoracic surgery needs and problems. conclusions: POP remains a relevant problem after lung resections. adoption of VATS approaches should be encouraged by virtue of a protective effect, ideally in the context of a multidisciplinary program. however, preventive strategies should undergo a focused evaluation, with adequately powered clinical trials.