Single-Lumen Endotracheal Ventilation With Capnothorax For Prone Thoracoscopic Esophageal Surgery: Anesthetic Management In A Case Series of Three Patients

Abstract

Introduction: One-lung ventilation (OLV) through a double-lumen tube is the conventional technique for thoracoscopic esophageal surgery, but it carries risks of hypoxemia, airway trauma and tube malposition. Two-lung ventilation through a single-lumen tube combined with controlled CO₂ insufflation (capnothorax) has been proposed as an alternative, particularly in the prone position.

Case presentation: We describe three patients who underwent prone video-assisted thoracoscopic surgery (VATS) for esophageal lesions: a 17-year-old girl with an esophageal duplication cyst, a severely undernourished 60-year-old man (BMI 14.8 kg/m²) with esophageal carcinoma undergoing esophagectomy, and a 45-year-old woman with an esophageal gastrointestinal stromal tumor (GIST). All were managed with a single-lumen endotracheal tube, gravity-assisted lung displacement in the prone position, controlled CO₂ insufflation, and low-tidal-volume ventilation with permissive hypercapnia (maximum recorded end-tidal CO₂ 42–45 mmHg). Regional analgesia (erector spinae plane block or thoracic epidural) was used in two patients. Surgical exposure was adequate in all cases without conversion to OLV; no clinically significant desaturation or hemodynamic instability occurred, all patients were extubated in the operating room, and recovery was uneventful.

Conclusion: In these selected patients, single-lumen ventilation with capnothorax was feasible for prone thoracoscopic esophageal surgery. Given the small, heterogeneous sample and exclusive use of the prone position, these observations are hypothesis-generating and do not establish the technique as an equivalent alternative to OLV; controlled studies, including in the lateral decubitus position, are needed.