Background: Tumor Spread Through Air Spaces (STAS) is a histopathological pattern of invasion associated with aggressive behavior in lung adenocarcinoma. Its prognostic impact and implications for surgical strategy remain controversial. This study evaluated the impact of STAS on survival and recurrence outcomes in patients undergoing uniportal video-assisted thoracoscopic surgery (U-VATS) for lung adenocarcinoma. Methods: We retrospectively analyzed consecutive patients with histologically confirmed lung adenocarcinoma who underwent U-VATS resection between January 2020 and January 2023 at a single tertiary referral center. Propensity score matching (1:1) was performed to reduce selection bias between STAS-positive and STAS-negative patients. Overall survival (OS) and recurrence-free survival (RFS) were analyzed using Kaplan–Meier estimates and log-rank tests. Multivariable Cox proportional hazards regression models were used to identify independent predictors of survival. Subgroup analyses were performed according to the type of resection. Results: Among 365 included patients, 111 (30.4%) were STAS-positive. After propensity score matching, 222 patients were analyzed (111 STAS-positive and 111 STAS-negative). STAS-positive patients showed a higher overall recurrence rate compared with STAS-negative patients (36.9% vs. 27.9%, p = 0.15), with a significantly increased rate of local parenchymal recurrence (18.9% vs. 9.0%, p = 0.03). No significant differences in OS or RFS were observed between matched groups. Multivariable Cox regression analysis confirmed that STAS was not independently associated with OS (HR 0.88, 95% CI 0.50–1.53, p = 0.643). In STAS-positive patients, sublobar resection was associated with significantly worse survival outcomes compared with lobectomy and emerged as an independent predictor of mortality (HR 2.61, 95% CI 1.14–5.97, p = 0.02). Conclusions: STAS was associated with an increased risk of local recurrence but was not independently associated with overall survival after U-VATS resection for lung adenocarcinoma. However, in STAS-positive patients, sublobar resection was independently associated with worse survival outcomes, suggesting that surgical extent plays a critical role in this subgroup. These findings support consideration of a personalized surgical approach in patients with STAS-positive lung adenocarcinoma.

Background/Objectives: Prolonged postoperative air leak (PAL) remains one of the most common complications after lung resection, significantly affecting postoperative recovery and healthcare utilization. While several preoperative risk factors have been identified, reliable intraoperative predictors are still lacking. This study aimed to evaluate whether intraoperative ventilator-derived parameters—volume decay (Vol-Decay) and pressure decay (Pres-Decay)—are associated with the development of PAL following uniportal video-assisted thoracic surgery (VATS) lung resection. Methods: We conducted a single-center study including 277 consecutive patients undergoing uniportal VATS lung resection for neoplastic disease between May 2023 and April 2024. At the end of the surgical procedure, intraoperative Vol-Decay and Pres-Decay were measured using the mechanical ventilator under standardized conditions. PAL was defined as an air leak persisting for more than 5 days within 30 days after surgery. Univariate and multivariate analyses were performed to identify independent predictors of PAL, and the optimal Vol-Decay cut-off was determined using Youden’s index. Results: PAL occurred in 18 patients (6.5%). At univariate analysis, higher smoking exposure, lower FEV1, lower FEV1/FVC ratio, and higher Vol-Decay were significantly associated with PAL. At multivariable analysis, only FEV1 (p = 0.013) and Vol-Decay (p = 0.038) remained independent predictors. The optimal Vol-Decay cut-off was 22 mL (AUC 0.64), with high specificity (0.94) but low sensitivity (0.34). Patients with Vol-Decay > 22 mL showed a significantly higher incidence of PAL compared to those with lower values (27.3% vs. 4.7%). Conclusions: Intraoperative Vol-Decay represents a simple, objective, and reproducible parameter associated with the development of prolonged air leak after uniportal VATS lung resection. Its measurement may enable real-time risk stratification and support personalized intraoperative decision-making, potentially guiding targeted corrective strategies. Further prospective multicenter studies are warranted to validate these findings and confirm their clinical applicability.