Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in the prone position for robot-assisted esophagectomy

Abstract

Background The prone position during robotic esophageal mobilization for minimally invasive esophagectomy (MIE) provides several advantages with regards to operative times, surgeon ergonomics, and surgical view; however, this technique requires one-lung ventilation (OLV). There are no guidelines about ventilatory modes during OLV in the prone position. We investigated the effects of volume-controlled (VCV) and pressurecontrolled ventilation (PCV) on oxygenation and intrapulmonary shunt during OLV in the prone position in patients who underwent robot-assisted esophagectomy. Methods Eighteen patients, no major obstructive or restrictive pulmonary disease, were allocated randomly to one of two groups. In the first group (n = 9), OLV was started by VCV and the ventilator was switched to PCV after 30 minutes. In the second group (n = 9), the modes of ventilation were performed in the opposite order in the prone position. Hemodynamic and respiratory variables were obtained during OLV at the end of each ventilatory mode. Results There were no significant differences in arterial oxygen tension (PaO 2 ), airway pressures, dynamic lung compliance, or physiologic dead space (Vd/Vt) during OLV between PCV and VCV in the prone position. Intrapulmonary shunt (Qs/Qt) was significantly lower with VCV than with PCV during OLV in the prone position (p = 0.044). Conclusion PCV provides no advantages compared with VCV with regard to respiratory and hemodynamic variables during OLV in the prone position. Either ventilatory mode can be safely used for patients who undergo robotassisted esophagectomy and who have normal body mass index and preserved pulmonary function.Keywords Minimally invasive esophagectomy Á One-lung ventilation Á Oxygenation Á Prone position Á Pressure-controlled ventilation Á Volume-controlled ventilation Prone positioning during robotic mobilization of the esophagus for minimally invasive esophagectomy (MIE) provides several advantages, including shortened operative times and superior surgical view, at the cost of one-lung ventilation (OLV) [1][2][3]. Surgical positions considerably influence the deterioration speed and the nadir value of arterial oxygen tension (PaO 2 ) after the start of OLV [4]. The development of hypoxemia during OLV depends mainly on the intrapulmonary shunt (Qs/Qt) through the nonventilated lung and matching of the ratio of ventilation and perfusion (V/Q) in the ventilated lung. In contrast to the lateral decubitus position, OLV in the prone position is devoid of the beneficial effect of gravity on preferential redistribution of the pulmonary blood flow to the dependent areas of a lung, possibly resulting in increased V/Q mismatch [4,5]. Also, the prone position is frequently associated with decreased respiratory compliance and

Better postoperative oxygenation in thoracoscopic esophagectomy in prone positioning

“…However, owing to recent developments in laparoscopic techniques, intrathoracic procedures can be performed using thoracoscopy. Prone positioning of the patient during an intrathoracic procedure facilitates optimal exposure of the esophagus by means of the anatomical orientation in the prone position, thereby affording an excellent surgical view [3]. Furthermore, good exposure of the esophagus is achieved by inducing a transitory pneumothorax using carbon dioxide (CO 2 ) [4].…”

Robot‐Assisted Thoracoscopic Hybrid Esophagectomy in the Semi‐Prone Position Under Pneumothorax

“…Compared with the standard da Vinci, da Vinci S is improved not only in the risk of arms and the high-definition vision system, but also in the length of the instruments, variation in available instruments, range of arm motion, and number of collisions between the arms. Most of the recent reports of robotic esophagectomy describe the use of da Vinci S (1,10,11), and these procedures cannot be performed using a 3-arm standard da Vinci system because of limitations arising from the number of arms and length of the instruments. Furthermore, the instruments available for use with a da Vinci Surgical System are still limited.…”

Intraoperative hypoxemia during one-lung ventilation: Is it still an anesthesiologists' nightmare? (hypoxemia during one-lung ventilation)

“…Indeed, initial studies comparing PCV and volume-control ventilation (VCV) during OLV found improved oxygenation and shunt fraction with PCV 15 , as well as the risk reduction for post-thoracotomy acute lung injury, but subsequent investigations failed to highlight benefit of PCV during OLV. 8,[16][17][18] Traditionally, the lateral decubitus position has been found to improve oxygenation during OLV due to gravity redistribution of pulmonary blood flow with diverting roughly 10% of CO to the dependent lung. 19 On the other hand, Yatabe et al found better PaO 2 /FiO 2 ratios in patients undergoing oesophagectomy in prone position.…”