Efficacy of artificial pneumothorax under two-lung ventilation in video-assisted thoracoscopic surgery for esophageal cancer

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One-lung ventilation (OLV) is the standard and widely applied ventilation approach used in video-assisted thoracoscopic surgery for esophageal cancer (VATS-e). To address the disadvantages of OLV with respect to difficulties in intubation and induction, as well as the risk of respiratory complications, two-lung ventilation (TLV) with artificial pneumothorax has been introduced for use in VATS-e. However, no studies have yet compared TLV and OLV with postoperative infection and inflammation in the prone position over time postoperatively. Here, we investigated the efficacy of TLV in patients undergoing VATS-e in the prone position.


Between April 2010 and December 2016, 119 patients underwent VATS-e under OLV or TLV with carbon dioxide insufflation. Clinical characteristics, surgical outcomes, and postoperative outcomes, including oxygenation and systemic inflammatory responses, were compared between patients who underwent OLV and those who underwent TLV.


Clinical characteristics other than pT stage were comparable between groups. The TLV group had shorter thoracic operation time than the OLV group. No patients underwent conversion to open thoracotomy. The PaO2/FiO2 ratios of the TLV group on postoperative day (POD) 5 and on POD7 were significantly higher than those of the OLV group. C-reactive protein levels on POD7 were lower in the TLV group than in the OLV group. There were no significant differences with respect to postoperative complications between the OLV and TLV groups. In the TLV group, the white blood cell count on POD7 was significantly lower than that in the OLV group; body temperature showed a similar trend immediately after surgery and on POD1.


In this study, we demonstrated that, compared with OLV, TLV in the prone position provides better oxygenation and reduced inflammation in the postoperative course. Accordingly, TLV might be more useful than OLV for ventilation during esophageal cancer surgery.

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The authors would like to thank Enago ( for the English language review.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

SN and HT conceived the idea of this research, designed the protocol, and supervised the analysis of the results. YI, SF, KK, MH, NI, YY, SH, DS, TI, KH, and YK developed and supervised all work and analyzed the results. HU supervised the study.

Correspondence to Hironori Tsujimoto.

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All authors (Shinsuke Nomura, Hironori Tsujimoto, Yusuke Ishibashi, Seiichiro Fujishima, Keita Kouzu, Manabu Harada, Nozomi Ito, Yoshihisa Yaguchi, Daizoh Saitoh, Takehiko Ikeda, Kazuo Hase, Yoji Kishi, Hideki Ueno) report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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Nomura, S., Tsujimoto, H., Ishibashi, Y. et al. Efficacy of artificial pneumothorax under two-lung ventilation in video-assisted thoracoscopic surgery for esophageal cancer. Surg Endosc (2020).

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  • Esophageal carcinoma
  • Two-lung ventilation (TLV)
  • One-lung ventilation (OLV)
  • Thoracoscopic esophagectomy
  • Prone position