Robot-assisted lobectomy versus completely portal robotic lobectomy: What is the difference?

Background: This study aims to compare robot-assisted lobectomy versus completely portal robotic lobectomy. Methods: Between January 2014 and December 2019, a total of 41 patients (10 males, 31 females; median age 62 years; range, 50 to 68 years) underwent robotic anatomical pulmonary resection in our institution were retrospectively analyzed. The patients were consecutively divided into two groups: the first 20 (48.8%) patients underwent pulmonary resection by robot-assisted lobectomy technique, while the next 21 (51.2%) patients underwent pulmonary resection by completely portal robotic lobectomy with four arms. Data including age, sex, diagnosis, surgery type and duration, rate of conversion to open surgery, and length of stay of the patients were recorded. The operation time, docking time, console time, and closure duration for each patient were also noted. Results: There was no statistically significant difference in age, sex, comorbidities, complications, length of hospital stay, adequate lymph node staging, or tumor size and side between the two groups (p>0.05). However, the mean console and operation times were statistically significantly shorter in the patients receiving completely portal robotic lobectomy with four arms (p=0.001). Conclusion: The advantage of completely portal robotic lobectomy with four arms is relative, although it significantly shortens the operation time. Based on our experiences, this technique may be preferred in case of inadequate lung deflation, as carbon dioxide insufflation allows sufficient workspace for robotic lung resection.

Relieving exertional dyspnea during the 3-min constant speed shuttle test in patients with COPD with indacaterol/glycopyrronium versus tiotropium: the RED trial

Background: Exertional dyspnea is a cardinal feature of chronic obstructive pulmonary disease (COPD) and a major cause of activity limitation. Although dual bronchodilation is more effective than bronchodilator monotherapy at improving resting pulmonary function, it is unclear to which extent this translates into superior relief of exertional dyspnea. Methods: We conducted a randomized controlled, double-blind, cross-over trial comparing indacaterol 110 µg/glycopyrronium 50 µg once daily (OD) with tiotropium 50 µg OD in patients with moderate to severe COPD and resting hyperinflation (functional residual capacity >120% of predicted value). The primary outcome was Borg dyspnea score at the end of a 3-min constant speed shuttle test after 3 weeks of treatment. Secondary outcomes included changes in Borg dyspnea score after the first dose of study medication, expiratory flows and lung volumes. Statistical analysis was conducted using a cross-over analysis of variance model with repeated measurements. Results: A total of 50 patients with COPD and a mean forced expiratory volume in 1 s of 54 ± 11% (mean ± SEM) predicted participated in the cross-over phase of the trial. Compared with baseline, there was a decrease in dyspnea after the first dose of medication with indacaterol/glycopyrronium [mean −1.00, 95% confidence interval (CI) −1.49 to −0.52] but not with tiotropium alone (mean −0.36, 95% CI −0.81 to 0.08). The reduction in dyspnea after the first dose was statistically significant between the two treatments (mean difference of −0.64, 95% CI −1.11 to −0.17). Despite indacaterol/glycopyrronium providing further bronchodilation and lung deflation throughout the trial, the reduction in dyspnea was not sustained at 3 weeks of treatment (mean between-treatment difference at 3 weeks of 0.09, 95% CI −0.44 to 0.61). Conclusion: In comparison with bronchodilator monotherapy, indacaterol/glycopyrronium provided greater immediate exertional dyspnea relief, although this difference was not sustained after 3 weeks of therapy despite evidence of further bronchodilation and lung deflation. The reviews of this paper are available via the supplemental material section.

Hypertonic saline stimulates vagal afferents that respond to lung deflation

In our present studies, we seek to determine whether increased osmolarity stimulates deflation-activated receptors (DARs). In anesthetized, open-chest, and mechanically ventilated rabbits, we recorded single-unit activities from typical slowly adapting receptors (SARs; responding only to lung inflation) and DAR-containing SARs (DAR-SARs; responding to both lung inflation and deflation) and identified their receptive fields in the lung. We examined responses of these two groups of pulmonary sensory units to direct injection of hypertonic saline (8.1% sodium chloride; 9-fold in tonicity) into the receptive fields. Hypertonic saline decreased the activity in most SAR units from 40.3 ± 5.4 to 34.8 ± 4.7 imp/s ( P < 0.05, n = 12). In contrast, it increased the activity in DAR-SAR units quickly and significantly from 15.9 ± 2.2 to 43.4 ± 10.0 imp/s ( P < 0.01, n = 10). Many units initially had increased activity, mainly in the deflation phase. DAR-SAR activities largely returned to the control level 30 s after injection. Since hypertonic saline stimulated DAR-SAR units but not SAR units, we conclude that hypertonic saline activates DARs.