Comparison of two-lung ventilation with CO₂ artificial pneumothorax and one-lung ventilation during esophagectomy: a retrospective cohort study

There is limited research data on the effect of different ventilation modes and airway devices on postoperative pulmonary complications (PPCs) during esophagectomy. Our single-center retrospective study aimed to compare the incidence of PPCs between two-lung ventilation (TLV) with CO₂ artificial pneumothorax using a single-lumen tube (SLT) and one-lung ventilation (OLV) using either a double-lumen tube (DLT) or a bronchial blocker (BB). Patients undergoing either open or minimally invasive surgeries on esophageal cancer between January 1st, 2022, and December 31st, 2024, at a tertiary teaching hospital were enrolled in the study. All the eligible cases were grouped based on the ventilation modes: TLV with CO2 artificial pneumothorax using an SLT and OLV with a DLT or a BB. The primary outcome was PPCs, which were defined with clinical manifestations and imaging findings, including pneumonia, hemothorax, hydrothorax, pulmonary atelectasis, acute respiratory distress syndrome (ARDS), and respiratory failure requiring mechanical ventilation. The secondary outcomes included pneumonia, in-hospital mortality, hospital length of stay (LOS), reoperation, anastomotic leak, infection, deep venous thrombus (DVT), chylothorax, and overall postoperative complications. A total of 455 patients were included, with 331 patients in the TLV cohort and 124 patients in the OLV cohort. According to the unadjusted and adjusted analyses, patients in the TLV cohort had a lower incidence of PPCs (31/331 vs. 20/124, 9.4% vs. 16.1%, unadjusted results: OR 0.5, 95% CI 0.3–0.9, P = 0.044; adjusted results: OR 0.3, 95% CI 0.2–0.7, P = 0.008) and pneumonia (27/331 vs. 18/124, 8.2% vs. 14.5%, unadjusted results: OR 0.5, 95% CI 0.3–0.9, P = 0.046; adjusted results: OR 0.4, 95% CI 0.2–0.9, P = 0.031) than patients in the OLV cohort. There were no significant differences between the cohorts in terms of LOS, and other postoperative complications. In the subgroup analysis, in which only minimal invasive esophagectomy was included, the incidence of PPCs and pneumonia was higher in OLV group than in TLV group (12/50 vs. 31/304, 24% vs. 10.2%, unadjusted results: OR 2.78, 95% CI 1.32–5.87, P = 0.007; adjusted results: OR 2.31, 95% CI 1.03–5.14, P = 0.041). No difference was found in pneumonia, in-hospital mortality, reoperation, anastomotic leak, infection, DVT, chylothorax, and overall postoperative complications in the MIE subgroup after adjustment. PPCs represent one of the most severe adverse events following esophagectomy. The use of TLV with CO₂ artificial pneumothorax via an SLT was associated with a lower incidence of PPCs in these patients. These findings underscore the potential advantage of TLV with CO₂ insufflation in enhancing perioperative outcomes.