Four-arm robotic lung resection versus muscle-sparing mini-thoracotomy: retrospective experience.

BACKGROUND: Robotic surgery was introduced in the early 2000s but its use remains limited, particularly in thoracic surgery. Here we compare the first consecutive 185 four-arm robotic procedures carried out in our institution vs. muscle-sparing video-assisted mini-thoracotomy (MSMT), our previous minimally invasive approach for anatomical lung resection. METHODS: One hundred and eighty-five consecutive patients undergoing surgery using the four-arm robotic technique between February 2014 and December 2016 were compared to a control historical series of 136 consecutive patients undergoing surgery by MSMT in the same institution. The same senior surgeon performed all surgical procedures. Comparisons between the two groups were performed using the Chi2 test for qualitative data and the Wilcoxon, Mann-Whitney or Student's t-test for quantitative data. RESULTS: The demographic and clinical characteristics of the patients were similar in the two groups. In the robotic group, median (min-max) length of hospital stay (LOS) was significantly shorter (by 2 days) than in the MSMT group {7 days [3-63] vs. 9 days [5-63], respectively; P<0.0001}. The rate of complications was similar in the two groups, but the complications appeared to be less severe in patients undergoing robotic surgery (switch from Clavien-Dindo grade III and IV to grade II) although further studies are required to confirm this due to the large number of missing data. CONCLUSIONS: In a senior thoracic surgery practice, the switch from a minimally invasive technique to robotic surgery was safe and beneficial in patients undergoing anatomical lung resection in terms of LOS and possible complication severity.

Failure of noninvasive ventilation after lung surgery: a comprehensive analysis of incidence and possible risk factors.

OBJECTIVE: Noninvasive ventilation has been successfully used after thoracic surgery. However, noninvasive ventilation fails in about 20% of patients. The aim of the study was to analyze episodes of noninvasive ventilation failure and to assess possible risk factors, while taking into account the performance of fiberoptic bronchoscopy for secretion management. METHODS: From January 2006 to June 2008, the use of noninvasive ventilation was prospectively recorded after thoracic surgery. Data were retrospectively abstracted from charts, including the number of fiberoptic bronchoscopies performed. Risk factors associated with noninvasive ventilation failure were evaluated using logistic regression analysis to estimate odds ratios (ORs) and their 95% confidence intervals (CIs). RESULTS: During the study period, 664 patients were admitted in the intensive care unit (ICU) after lung resection or pulmonary thromboendarterectomy. A total of 135 patients underwent noninvasive ventilation (20.3%). As many as 40 of these 135 patients needed to be intubated (29.6%) and represented the noninvasive ventilation failure group. Patients with noninvasive ventilation failure had more fiberoptic bronchoscopies performed compared with patients with noninvasive ventilation success: 3 (1-5) versus 1 (0-3); p = 0.0008. Four independent variables were associated with noninvasive ventilation failure during the first 48 h of appliance: increased respiratory rate (OR: 4.17 (1.63-10.67); increased Sequential Organ Failure Assessment (SOFA) score (OR: 3.05 (1.12-8.34); number of fiberoptic bronchoscopies performed (OR: 1.60 (1.01-2.54); and number of hours spent on noninvasive ventilation (OR: 1.06 (1.01-1.11). Nosocomial pneumonia was the leading cause of respiratory complications and occurred in 21 and 6 patients with and without noninvasive ventilation failure, respectively (53% vs 6%; p < 0.0001). Patients in the failure group had a higher mortality rate (20% vs 0%; p < 0.0001). CONCLUSIONS: Noninvasive ventilation failure is associated with higher mortality, but is merely a marker of progression of a more severe disease. This may at least indicate the need for caution in some patients. Interestingly, increased use of fiberoptic bronchoscopies during noninvasive ventilation appliance was identified as a risk factor of failure.

Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock.

STUDY OBJECTIVE: To assess the value of the global end-diastolic volume (GEDV) evaluated by transpulmonary thermodilution as an indicator of cardiac preload. DESIGN: Prospective clinical study. SETTING: Medical ICU of a university hospital (20 beds). PATIENTS: Thirty-six patients with septic shock. INTERVENTIONS: Volume loading and dobutamine infusion. MEASUREMENTS AND RESULTS: Hemodynamic parameters were evaluated in triplicate by the transpulmonary thermodilution technique: (1) before and after 66 fluid challenges in 27 patients, and (2) before and after 28 increases in dobutamine infusion rate in 9 patients. Volume loading induced a significant (p < 0.001) increase in central venous pressure (CVP) from 10 +/- 4 to 13 +/- 4 mm Hg, in GEDV index from 711 +/- 164 to 769 +/- 144 mL/m(2), in stroke volume index (SVI) from 36 +/- 12 to 42 +/- 12 mL/m(2), and in cardiac index (CI) from 3.4 +/- 1.1 to 3.9 +/- 1.2 L/min/m(2) (mean +/- SD). Changes in GEDV index were correlated (r = 0.72, p < 0.001) with changes in SVI, while changes in CVP were not. The increase in SVI was > 15% in 32 of 66 instances (positive response). The preinfusion GEDV index was lower (637 +/- 134 mL/m(2) vs 781 +/- 161 mL/m(2), p < 0.001) in the cases of positive response, and was negatively correlated with the percentage increase in GEDV index (r = - 0.65, p < 0.001) and in SVI (r = - 0.5, p < 0.001). Dobutamine infusion induced an increase in SVI (32 +/- 11 mL/m(2) vs 35 +/- 12 mL/m(2), p < 0.05) and in CI (2.8 +/- 0.6 L/min/m(2) vs 3.2 +/- 0.6 L/min/m(2), p < 0.001) but no significant change in CVP (13 +/- 3 mm Hg vs 13 +/- 3 mm Hg) and in GEDV index (823 +/- 221 mL/m(2) vs 817 +/- 202 mL/m(2)). CONCLUSION: In patients with septic shock, our findings demonstrate that, in contrast to CVP, the transpulmonary thermodilution GEDV index behaves as an indicator of cardiac preload.

Chemokine RANTES in severe pulmonary arterial hypertension.

The recent discovery that sporadic and familial primary pulmonary hypertension can be associated with germline mutations of genes encoding receptor members of the transforming growth factor-beta family has focused much attention on cytokines and growth factors in pulmonary vascular disorders. Production of several cytokines has been demonstrated in severe pulmonary arterial hypertension, emphasizing the possible influence of inflammatory mechanisms in this condition. Moreover, perivascular inflammatory cell infiltrates composed of macrophages and lymphocytes have been detected in plexiform lesions of primary pulmonary hypertension. Chemokine RANTES is an important chemoattractant for monocytes and T cells. We therefore hypothesize that chemokine RANTES promotes cell recruitment in the lungs of patients displaying severe pulmonary arterial hypertension. Reverse transcriptase polymerase chain reaction demonstrated elevated RANTES mRNA expression in 10 lung samples from patients with severe pulmonary arterial hypertension, as compared with seven control subjects. In situ hybridization and immunohistochemistry confirmed that endothelial cells were the major source of RANTES within the pulmonary artery wall of the patients. Serial sections analysis showed that RANTES expression was associated with CD45+ inflammatory cell infiltrates. These results support the concept that inflammatory mechanisms play a role in the natural history of pulmonary arterial hypertension.