Optimization of robot-assisted thoracoscopic esophagectomy in the lateral decubitus position

Background

On the introduction of robot-assisted thoracoscopic esophagectomy (RATE), we refined the robotic system application to enhance our surgical experience obtained through thoracoscopic esophagectomy (TE) in the lateral decubitus position (LDP). Herein, we evaluate our methods introduced to optimize RATE in the LDP.

Methods

We performed RATE in the LDP with camera rotation and manual hand control assignment to reproduce the surgical view and manipulation of open esophagectomy. Forty patients underwent RATE between July 2018 and August 2020. After the initial 30 cases (initial RATE group), we optimized the port arrangement and robot settings in the most recent ten cases (recent RATE group). The surgical results of RATE were compared with those of 30 patients underwent TE between April 2014 and May 2019 selected by propensity score-matched analysis based on cStage (TE group).

Results

Operative duration was significantly longer in the initial RATE group than the TE group and the recent RATE group. Thoracic blood loss was significantly less in the initial RATE group than the TE group. Console time was significantly shorter in the recent RATE group than the initial RATE group. There was no surgical mortality in RATE and the surgical morbidity rate was similar in the three groups.

Conclusions

Camera rotation and manual hand control assignment during RATE in the LDP reproduced the surgical view and manipulation of open esophagectomy and TE in the LDP. The robotic platform enabled meticulous dissection and reduced blood loss, but was initially time-consuming. Optimization of the port arrangement minimized operative duration.

     

晚期妊娠左侧卧位的循证护理研究

为了探讨孕妇妊娠晚期左侧卧位的必要性,对31例晚期妊娠孕妇和25例年龄相仿的未孕妇女用心率变异谱分析进行研究;比较她们在仰卧位、右侧和左侧卧位时心率变异性的时域和频域分析资料,结果表明,未孕妇女标化的高频功率在右侧卧位时最大。而孕妇在仰卧位时标化的高频功率最低;并且低频与高频功率之比最大。因此,左侧卧位对晚期妊娠是有益的,因为心迷走神经张力的降低和心交感神经兴奋性的增加最小。     

Pelvic tilt and movement during total hip arthroplasty in the lateral decubitus position

Objectives: Total hip arthroplasty (THA) is often performed in the lateral decubitus (lateral) position. In this position, the pelvis may have various degrees of tilt leading to implant malposition. We sought to quantify the pelvic tilt in lateral position and further pelvic movement during surgery.

Methods: In 95 cases with primary THA, three-dimensional pelvic tilts were quantified by superimposing images reconstructed from CT data onto antero-posterior radiographs taken in lateral position at set-up and after cup placement. Pelvises were fixed with a device compressing anterior superior iliac spines and sacrum.

Results: Various degrees of pelvic tilt occurred compared to the supine position; sagittal:??3.1° (?25.5° to 10.2°), axial: 3.9° (?8.4° to 17°), coronal: 0.9° (?11.9° to 13.2°). Absolute changes more than 5° were observed 43%, 47%, and 12% in the sagittal, axial, and coronal planes, respectively. The more preoperative posterior pelvic tilt resulted in the more change in the sagittal plane. Further pelvic movement of about 3° in three planes were observed ranging from??11° to 20° after cup placement.

Conclusion: This study showed various pelvic tilt and movement during THA. As pelvic tilt directly alters the cup orientation, its changes should be well understood. Improved tools for positioning and holding the pelvis are required.     

Effect of lateral positions on tissue oxygenation in the critically ill.

OBJECTIVE: The purpose of this study was to assess the effect of lateral positions on tissue oxygenation in critically ill patients. DESIGN: The study design was prospective and quasi-experimental, and we used a convenience sample with random assignment. SETTING: The study took place in the intensive care unit and the cardiac intensive care unit of a 450-bed medical center in the northwestern United States. PATIENTS: The sample included 12 adult patients with indwelling pulmonary artery and radial arterial catheters who were receiving mechanical ventilation and who met the criteria of "critical illness" by having impaired arterial oxygenation (PaO2 < or = 70 mm Hg) and/or cardiac index < or = 2.0 L/min/m2. OUTCOME MEASURES: The outcome measures were dependent variables reflecting oxygen delivery including heart rate, cardiac output, arterial oxygen content (CaO2) and oxygen consumption, and the adequacy of tissue oxygenation (serum lactate). INTERVENTION: Each patient was passively turned to each of the three positions (right and left 45 degrees lateral and supine) according to a computer-generated, randomized positioning sequence. Dependent variables were measured 15 minutes after each position change. No changes in ventilator settings or vasoactive drugs occurred during data collection. RESULTS: Analysis of variance for repeated measures was used in the data analysis. Post hoc analysis determined an effect size of 0.558 and power of 0.80 at an alpha level of.05. No statistically significant differences caused by position were found in mean CaO2, cardiac output, heart rate, respiratory rate, PaO2, SaO2, or lactate level. Pearson correlation analysis found no significant relationships between the primary variables reflecting oxygen delivery (cardiac output and CaO2) and serum lactate levels. CONCLUSIONS: These findings suggest that lateral positioning of critically ill patients who are hypoxemic or have low cardiac output does not further endanger tissue oxygenation. Evaluation of individual patient responses to position changes in the clinical setting is encouraged until further studies using more heterogenous populations can provide more definitive guidance.     

Right lateral decubitus position reduces QT dispersion in patients with chronic heart failure

A greater QT dispersion in patients with chronic heart failure (CHF) appears to be a non-invasive marker of susceptibility to malignant ventricular arrhythmias. We evaluated whether QT dispersion in CHF patients is modified by the patients' recumbent position. In 12 CHF patients, and age and sex-matched 12 normal subjects, a single 12-lead surface ECG was recorded in each postural position [left lateral decubitus position (L), supine position (S), and right lateral decubitus position (R)]. In normal subjects, the QT dispersion was comparable in the three recumbent positions [L: 47+/-15 (SD) ms, S: 40+/-9 ms, R: 38+/-14 ms, P=NS]. In contrast, in CHF patients, QT dispersion was significantly shorter in R than those in L and S (L: 93+/-42 ms*, S: 81+/-29 ms*, R: 63+/-24 ms, *P <.05 vs. R). In conclusion, reclining in R reduces the prolonged QT dispersion in CHF patients.     

Elevated non-transferrin bound iron in the lungs of patients with Pneumocystis carinii pneumonia

OBJECTIVE: The aim of the present work was to determine the concentrations of iron and iron-binding proteins in the lungs of patients suffering from Pneumocystis carinii (PCP), which is crucial for justifying the treatment with iron-chelating agents in this disease. PATIENTS AND METHODS: Bronchoalveolar lavage was performed in 10 HIV patients with PCP and five healthy controls. Total iron and iron-binding proteins (transferrin, ferritin and lactoferrin) were measured in acellular bronchoalveolar lavage fluid (BALF) in both groups. Iron was determined by atomic absorption spectrometry; transferrin and lactoferrin were measured using specific enzyme-linked immunosorbent assays (ELISA); and ferritin concentration was quantified by automated immunonephelometry. RESULTS: Our findings in patients with PCP demonstrated a six- to seven-fold increase of total iron levels and an eight-fold increase of ferritin in bronchoalveolar lavage fluid when compared with controls. No significant differences were found in transferrin or lactoferrin levels. Moreover, our results suggest that this iron is non-transferrin bound. CONCLUSION: Non-transferrin bound iron is increased in the lower respiratory tracts of PCP patients. This finding would lend experiment support to the use of iron-chelating agents in this disease.     

Differentiation of cardiac murmurs by dynamic auscultation

The techniques described in this monograph will aid in the accurate identification of the origin of a cardiac murmur or abnormal heart sound. They do not necessarily reveal the presence or severity of cardiac disease. No maneuver is 100% accurate in elucidation of cardiac abnormalities, and a given maneuver's effectiveness varies in its application. The systematic application of a combination of maneuvers improves the accuracy of diagnosis. Auscultatory findings must be interpreted with consideration of the total clinical examination including history, other physical findings, ECG, chest x-ray, and possibly an echocardiogram. Thus, the careful physiological approach to the physical examination represents a powerful noninvasive tool that can be used in combination with other information to accurately diagnose cardiac disease in many patients and efficiently direct further evaluation when necessary.     

Bronchiolitis obliterans organizing pneumonia and bronchogenic carcinoma coexisting in different parts of the lungs

Bronchiolitis obliterans organizing pneumonia (BOOP) coexisting with nonsmall cell lung cancer in a separate part of the lungs is rare. We report the case of a man diagnosed with BOOP by video-assisted thoracoscopic lung biopsy; the patient also had adenocarcinoma in a different part of the lungs. The BOOP was treated with corticosteroids and the carcinoma was surgically resected. Outcome and clinical course were good after both procedures. The possibility of BOOP associated with bronchogenic carcinoma at a distant part of the lungs, although rare, must be taken into account in the differential diagnosis of radiographic alterations that may present in either of the 2 diseases.     

Detection of coronavirus in experimental pneumocystic pneumonia

Transmission electron microscopy (of ultrathin sections) was used to examine the biomass of lung tissue in the immunodeficiency minipigs experimentally infected with Pneumocystis carinii. The material was found to contain pneumocysts, bacteria, and coronaviruses. There was a clear coronavirus-pneumocyst structural relationship. The findings suggest the combined effect of microorganisms of different systematic groups on the development of a pathological process in the experimental infection etiologically determined by Pneumocystis carinii.