The future of lung cancer surgery lies between innovations: synergy across the perioperative ERATS pathway

Surgical resection remains the treatment of choice for early-stage lung cancer. Over the past few decades, enhanced recovery after thoracic surgery (ERATS) programs, including preoperative optimization, minimally invasive surgery, opioid-sparing analgesia, early mobilization, patient engagement, and rehabilitation strategies, have been implemented as part of integrated care pathways for lung surgery, aimed at reducing surgical stress and improving functional recovery. Increasing adherence to isolated perioperative care pathway components is associated with a reduction in length of hospital stay, consistent with the 'marginal gains' paradigm, whereby the cumulative implementation of multiple ERAS elements confers greater benefit than any single intervention alone. However, evidence-based studies mainly focus on single interventions throughout the perioperative care pathway, and the synergistic effect remains inadequately studied yet. As, individual classic components of ERATS pathways are under development, and innovative versions emerge, this review summarizes contemporary developments across the pre-, intra-, and postoperative phases of lung cancer surgery, focusing on prehabilitation, three-dimensional (3D) imaging, uniportal robot-assisted thoracoscopic surgery (uRATS), non-intubated video-assisted thoracoscopic surgery (NI-VATS), locoregional anesthesia techniques, and drainless surgery. Furthermore, we explore their potential synergistic role in optimizing recovery after lung cancer surgery.