Objectives: To evaluate outcomes of patients undergoing lung segmentectomy using open thoracotomy, Video-Assisted Thoracoscopic Surgery (VATS), or Robotic-Assisted Thoracoscopic Surgery (RATS) approaches. Methods: A total of 157 patients (mean age: 68.7 years; 58% male) who underwent lung segmentectomy from 2015 to 2024 at the Thoracic Surgery of Siena were retrospectively enrolled and divided into groups based on the surgical approach: thoracotomy (n = 60), VATS (n = 58), and RATS (n = 39). No significant differences were observed between groups in terms of age, gender, or tumor stage. Peri-operative outcomes, and, in patients with non-small cell lung cancer (NSCLC, n = 104), long-term outcomes, were analyzed. Group comparisons were conducted using Kruskal–Wallis, Dunn’s test, Chi-squared, or Fisher’s exact test and Kaplan–Meier analysis with log-rank test. Results: Conversion rate was 13% and 0% for VATS and RATS, respectively (p = 0.005). Pleural effusion on first post-operative day was lower in RATS than VATS (p = 0.0006) and open (p < 0.0001). The maximum Visual Analogue Scale (VAS) value recorded was lower in RATS than open (p = 0.016) and VATS (p = 0.013). Surgery time was longer for RATS than open (p = 0.001) and VATS (p = 0.013). No differences were found in hospital stay and post-operative complications. In patients with NSCLC, the median follow-up was 25 months. The 90-day mortality rate was 9.5% in thoracotomy, 0% in VATS and RATS (p = 0.05). The 1- and 2-year overall survival was higher in VATS and RATS groups than thoracotomy (p = 0.001 and p = 0.040, respectively). The number of harvested lymph nodes was larger in the open group (p = 0.010), while a higher number of stations were harvested in RATS and open than VATS (p = 0.001). No differences were found in local recurrence (p= 0.08). Conclusions: RATS segmentectomy ensures a lower conversion rate, less post-operative pain, reduced daily pleural effusion, and a greater number of harvested lymph node stations compared to VATS, providing comparable peri-operative outcomes. RATS and VATS segmentectomy offer an advantage over the open approach in short- and long-term survival.

Background: Regional anaesthesia techniques allow postoperative pain control while reducing opioid consumption. Ketamine is another viable option for minimising perioperative opioid use. We evaluated the efficacy of a perioperative multimodal analgesia protocol incorporating paravertebral block (PVB) and ketamine infusion in patients undergoing video-assisted thoracic surgery (VATS). Methods: This retrospective single-centre study divided patients into two groups: the opioid-sparing (OS) group receiving PVB and ketamine (n = 41), and the control group (n = 21) treated with postoperative morphine infusion. The primary outcome was the need for rescue opioid therapy; secondary outcomes included postoperative pain scores assessed at multiple time points over 48 h using the numeric rating scale (NRS), prevalence of chronic postoperative pain at three months, perioperative haemodynamics, and hospital length of stay. Results: Rescue opioid administration was significantly lower in the OS group (19.5% vs. 47.6%, p = 0.021). Upon awakening, pain control was better in the OS group (1 [1–2] vs. 4 [3–4], p < 0.001); however, pain scores did not differ afterwards. Chronic postoperative pain was less common in the OS group (n = 10/41; 23.8% vs. n = 11/21, 52.4%; p = 0.028). No differences in haemodynamics were reported, nor were there any ketamine/PVB-related complications. No difference in length of hospital stay was observed between the groups. The ketamine starting dose and postoperative morphine requirements were inversely correlated (rho = −0.380; p = 0.002). Conclusions: A multimodal analgesia protocol integrating PVB and ketamine infusion in patients undergoing VATS may effectively reduce postoperative opioid consumption, improving analgesia in the initial postoperative period.

BACKGROUND: Actinomycosis by Actinomyces meyeri is rare and scarcely reported in the literature. The lung is the main organ involved. Penicillin and amoxicillin are the first-choice treatments. Surgery is indicated when empyema and abscesses are resistant to medical treatment. CASE PRESENTATION: We report an underdiagnosed case of pleural empyema due to A. meyeri in a patient with closed chest trauma. The patient, a male, 47 years old, presented with a dry cough, thoracic pain, and dyspnea a month after the trauma. A chest X-ray showed a left lower lobe pleural effusion, so he was subjected to a thoracentesis, leading to a partial re-expansion of the left lung. The patient also complained about gum discomfort; thus, a dental x-ray scan was taken, which showed the presence of vertical bone resorption in a periodontal pocket. The patient was treated with levofloxacin 500 mg orally once a day, which was continued for 15 days after discharge. Two months after the accident, he presented again with intermittent fever, a worsening cough, and dyspnea. A CT scan showed thickening of the left pleura and a loculated pleural effusion with partial collapse of the left lower lobe. A decision was made to refer the patient to the Thoracic Unit to undergo surgery via a left thoracoscopic uniportal approach. The lung was thoroughly decorticated, and the purulent fluid was aspirated. The postoperative course was uneventful. Cultures showed the growth of Actinomyces meyeri, which is sensitive to imipenem and amoxicillin. The patient started a proper antibiotic regimen and, whenever possible, was discharged. At 12 months follow-up, a chest X-ray showed a complete resolution of the left pleural effusion with complete re-expansion of the left lung. CONCLUSIONS: Although rare, Actinomycetes infections must be considered especially in front of non-solving empyema or severe pneumonia of unknown cause because in the majority of cases, with the proper treatment, the restitutio ad integrum is possible.

Penetrating neck and chest trauma is a very common entity in emergency medicine that usually requires surgical treatment. Our case report illustrates the case of a 27-year-old Arabian man with hemopneumothorax associated with pneumomediastinum due to an unusual occupational injury. A metal sliver, coming from an axe using for wood chopping, penetrated the neck of a 27-year-old Arabian man in the left supraclavicular region mimicking a gun bullet; the entrance hole was at the left pleural dome where the sliver had just penetrated the apex of the lung passing through the upper lobe of his left lung creating an exit wound in the dorsal segment of the same lobe arriving in the posterior thoracic wall. Biportal video-assisted thoracic surgery was performed to remove blood clots and the unusual foreign body. In the literature, there are several case series about this topic, with some of them reporting unusual foreign bodies that lead to penetrating trauma. However, to the best of our knowledge, no cases like the one we have reported are described in the current literature.