Effect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy On Respiration and Circulation

Effect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy On Respiration and Circulation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Effect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy On Respiration and Circulation Haibo Ye, Xiaojin Wang, Xiaojian Li, Xiangfeng Gan, Hongcheng Zhong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-642915/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background and Purpose We previously developed a new surgical method, namely, single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy. The purpose of this study was to evaluate the effect of carbon dioxide inflation on respiration and circulation using this approach. Methods From April 2018 to October 2020, 105 patients underwent this novel surgical approach. The changes in respiratory and circulatory functions were reported when the mediastinal pressure and pneumoperitoneum pressure were 10 and 12mmHg, respectively. Data on blood loss, operative time, and postoperative complications were also collected. Results 104 patients completed the operation successfully, except for 1 patient who was converted to thoracotomy because of intraoperative injury. During the operation, respectively, the heart rate, mean arterial pressure, central venous pressure, peak airway pressure, end-expiratory partial pressure of carbon dioxide and partial pressure of carbon dioxide increased in an admissibility range. The pH and oxygenation index decreased 1 hour after inflation, but these values were all within a safe and acceptable range and restored to the baseline level after CO 2 elimination. Postoperative complications included anastomotic fistula (8.6%), pleural effusion that needed to be treated (8.6%), chylothorax (0.9%), pneumonia (7.6%), arrhythmia (3.8%) and postoperative hoarseness (18.2%). There were no cases of perioperative death. Conclusions When the inflation pressure in the mediastinum and abdomen was 10 mmHg and 12 mmHg, respectively, the inflation of carbon dioxide from single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy did not cause serious changes in respiratory and circulatory function or increase perioperative complications. Cardiac & Cardiovascular Systems Cardiothoracic Surgery Esophagectomy inflatable mediastinoscopy circulation respiration Figures Figure 1 Figure 2 Figure 3 Introduction Esophageal cancer (EC) is one of the most common malignant tumors in the world, ranking seventh in global morbidity and sixth in mortality 1 . The prognosis of EC is poor, and the 5-year survival rate is less than 25% 2 . Currently, the basic treatment strategy for EC is a combination of surgery, radiotherapy and chemotherapy, and surgical treatment is still the main and preferred treatment 2 , 3 . Previous studies have shown that compared with open esophagectomy, minimally invasive esophagectomy (MIE) has the advantages of less postoperative pain, less intraoperative bleeding, shorter hospital stay and recovery time, and more extensive lymph node dissection. Thus, MIE has become the preferred surgical method 4 – 8 . The approaches of MIE are transthoracic and non-transthoracic (e.g., transhiatal esophagectomy). Transhiatal esophagectomy (THE) is considered to be less invasive and has fewer pulmonary complications because it avoids thoracotomy 9 . However, traditional THE has more stringent surgical indications because of its limited field of vision and insufficient mediastinal lymph node dissection, which is more suitable for cancers that indicate negative lymph nodes, and the oncology results are usually considered poor 10 , 11 . To overcome this shortcoming, Fujiwara et al developed a new surgical method, namely, a radical resection of thoracic EC by using inflatable mediastinoscopic lymph node dissection through cervical incisions and hand-assisted laparoscopic lymph node dissection of the upper mediastinum, and this method has been reported to be safe and feasible 12 – 14 . On this basis, our organization further improved the operation and carried out single-port inflatable mediastinoscopy simultaneous laparoscopic radical esophagectomy (SPIMSLE) 15 .Our team improved this operation as following differences: first, our team is divided into mediastinal group and abdominal group to operate at the same time, and the operation time is significantly shortened; second, our abdominal group is operated completely under laparoscopy. rather than hand-assisted laparoscopic surgery, the trauma is less. Third, we have performed lymph node dissection of the right vagus nerve and the right recurrent laryngeal nerve through the left cervical incision 16 . In this procedure, we inflated the mediastinum and abdomen to provide a clear field of view for esophagectomy and mediastinal lymph node dissection. This operation, which is a relatively new surgical method, is not performed through the chest or one-lung ventilation and causes less damage to the lungs. Whether simultaneous inflation of the mediastinum and abdomen during surgery has a significant impact on the respiratory and circulatory systems has not been reported. The purpose of this study was to evaluate the perioperative safety of this procedure. Materials And Methods From April 2018 to October 2020, patients with esophageal malignant tumors were treated with SPIMSLE in the Fifth Affiliated Hospital of Sun Yat-sen University. The inclusion criteria were as follows: (1) pathologically confirmed malignant tumor and The preoperative T stages were T1b-T3 ; (2) functional tolerance of major organs and systems for radical surgery; (3) no other cancers; (4) no history of mediastinal surgery; The exclusion criteria were as follows: (1) cervical EC;(2) refusal of surgery. This study was approved by the institutional review committee of our hospital. Written informed consent was obtained from each patient. Anesthesia : Preoperative medication included intramuscular injection of atropine 0.01mg/kg. Anesthesia was induced by intravenous injection of midazolam 0.05mg/Kg, propofol 2mg/kg, muscle relaxant cis atracurium 0.15 ~ 0.25mg/kg and sufentanil citrate 0.1-0.3ug/Kg. Insert 7/7.5-FR single lumen catheter (Sheridan endotracheal catheter, Sher-I-Bronch). Do not use bronchial blockers. Mechanical ventilation after intubation (tidal volume 6–8 ml / kg; inspiratory time / expiratory time ratio: 1 / 1.5). Adjust the respiratory rate and do not use positive end-expiratory pressure. Anesthesia was maintained by continuous intravenous infusion of remifentanil 0.25g -1.0g / kg / min, while inhaling air, oxygen and sevoflurane. After operation, the tube was extubated after the recovery of pharynx reflex, inhalation and ventilation. All intubation procedures are performed by experienced anesthesiologists. Surgical Procedure The patients were ventilated with single-lumen endotracheal intubation under general anesthesia in the supine position; central venous pressure (CVP) was recorded by a central venous catheter in the right subclavian vein; and blood pressure was monitored by an indwelling arterial catheter in the right radial artery. The operation was performed by two groups of people through the cervical incision via the mediastinoscope and the abdomen via the laparoscope at the same time, and the surgical incision and surgeon's location were performed as described in our recent report 15 , 17 . The operation in the mediastinal group was performed as follows: first, access was gained through the cervical incision, and the cervical esophagus was freed, establishing a tunnel filled with carbon dioxide (CO 2 ) gas to create artificial mediastinal emphysema and obtaining a pressure of 10 mmHg. After we methodically tried various pressure gradients, when the mediastinal pressure was 10 mmHg, the operative field was clear, and the operative space was wide. Second, we continued to dissociate the upper and middle thoracic esophagus and dissected the lymph nodes in the thoracic region. The operation in the abdomen group was performed as follows: the artificial pneumoperitoneum pressure was 12 mmHg, which is the conventional laparoscopic operative pressure. The stomach was dissociated, and the lymph nodes in the abdominal region of the esophagus were dissected. Next, the lower thoracic esophagus was dissociated through the diaphragmatic esophageal hiatus, and the surrounding lymph nodes were cleared. Finally, it penetrated the superior mediastinum. The air source was turned off, and inflation was stopped. The esophagus was incised at the neck, the Tubular stomach was created, and the neck was anastomosed with the proximal esophagus through the esophageal bed. The neck and abdominal incisions were sutured. Observation Parameters : Heart rate (HR), invasive mean arterial pressure (MAP), central venous pressure (CVP), peak airway pressure (AP), end-expiratory CO 2 partial pressure (ETCO 2 ), inhaled oxygen concentration (FiO 2 ) and tidal volume (TV) were continuously monitored and recorded during the operation. Arterial blood samples were collected for blood gas analysis at the following time points: 5 minutes before inflation of the mediastinum and abdomen (baseline); 1 hour after inflation; 20 minutes after CO 2 excretion; and 10 minutes after the operation. These data were collected from anesthetic records. At the same time, the operative duration, amount of bleeding, and A special event during the operation were recorded. Postoperative pathological data, postoperative complications, and postoperative hospital stay information were collected. Statistical Analysis Continuous data are expressed as the mean ± standard deviation (SD). The classified data are expressed as a percentage. During the operation, taking the pre-inflation data as the reference, the Welch test was used to analyze the numerical difference in each period after inflation. All statistical analyses were conducted using IBM SPSS version 25 (SPSS Statistics v25, IBM, Somers, NY, USA). When P < 0.05, the result was considered significant. Results A total of 105 patients who underwent SPIMSLE from April 2018 to October 2020 were enrolled. The demographic and clinical characteristics of the 105 patients are summarized in Table 1 . The average age was 62.6 ± 8.8 years (range 42–84 years), the percentage of vital capacity (VC) was 70.5-176.1% (101.68 ± 23.00%), the percentage of forced expiratory volume to predicted value within 1 s (FEV1%) was 67.9-163.3% (100.05 ± 20.80%), and the average cardiac ejection fraction was 69.35 ± 5.11. The tumor sites included the upper chest (n = 14), middle chest (n = 56) and lower chest (n = 35). The preoperative T stages were as follows: T1b, 36 patients; T2, 49patients; and T3, 20 patients. Comorbidities included COPD (n = 6), hypertension (n = 27) and diabetes (n = 9). Twenty-one of these patients received neoadjuvant chemotherapy. Table 1 Patient demographics and clinical characteristics Parameters Number Age Average (range) 62.6(42–84) Gender Male 75 Female 30 Tumor location Upper thoracic segment 14 Middle thoracic 56 Lower thoracic 35 Biopsy pathology Squamous cell carcinoma 99 Adenocarcinoma 1 Small cell carcinoma 1 Sarcomatoid carcinoma 1 Neuroendocrine Carcinoma 3 The preoperative T stages T1b 36 T2 49 T3 20 Concomitant disease COPD 6 Hypertension 27 Diabetes 9 Atrial fibrillation 2 Preoperative treatment Neoadjuvant Chemotherapy 21 Neoadjuvant radiotherapy 0 Intraoperative observation index There were no deaths within 30 days postoperatively. A total of 104 patients underwent SPIMSLE, and 1 patient underwent thoracotomy because of tracheal membrane injury during mediastinoscopy. Pleural rupture occurred in 5 cases, and the airway pressure increased immediately after pleural rupture, up to 4 cmH 2 O. The effect of tension pneumothorax on the operation could be avoided by suspending the operation for several minutes, properly reducing tidal volume and enlarging the scope of rupture. The average operative time was 186.7 ± 43.9 minutes, and the average intraoperative blood loss was 113.4 ± 89.9 ml. The field of view was clear during the operation, and the average number of lymph nodes dissected was 22.5 ± 4.5. During the operation, the hemodynamics and respiratory movement indexes of 104 cases were monitored when CO 2 was inflated into the mediastinum and abdomen synchronously, as shown in Table 2 . The data from 5 minutes before CO 2 inflation were taken as the baseline, and there were significant differences in HR, MAP, CVP, Peak AP, ETCO 2 , PH, oxygenation index (OI, the ratio of inhaled oxygen concentration to the partial pressure of oxygen) and partial pressure of CO 2 (PaCO 2 ) after inflation. Table 2 Changes in the respiratory and circulatory systems before and after inflation intraoperatively. Inflatable stage 5 min before inflation (baseline) 5 min 10 min 20 min 1 h 20 min after gas shutdown Postoperative 10 min HR 69.1 ± 7.9 87.6 ± 15.5 * 89.8 ± 16.7 * 90.2 ± 16.5 * 88.6 ± 14.3 * 77.9 ± 12.8 73.0 ± 10.0 MAP 84.8 ± 6.4 103.4 ± 14.8 * 104.3 ± 14.5 * 97.9 ± 14.5 * 98.2 ± 13.3 * 90.6 ± 6.2 97.5 ± 10.6 CVP 6.3 ± 0.9 14.5 ± 1.5 * 14.0 ± 1.9 * 14.0 ± 1.6 * 14.6 ± 1.7 * 10.1 ± 1.6 9.0 ± 1.4 Peak AP 14.3 ± 1.6 21.7 ± 3.2 * 23.1 ± 3.9 * 23.0 ± 4.5 * 23.4 ± 4.9 * 15.5 ± 2.4 14.9 ± 2.2 ETCO 2 33.4 ± 3.4 39.6 ± 3.3 * 40.5 ± 5.8 * 40.9 ± 5.9 * 43.1 ± 5.6 * 36.0 ± 3.4 34.6 ± 2.8 TV 403.2 ± 51.4 395.6 ± 49.2 378.6 ± 70.8 379.5 ± 50.0 354.9 ± 41.9 * 365.8 ± 42.5 377.6 ± 43.0 OI 474.6 ± 71.8 316.2 ± 94.6 * 360.6 ± 80.1 * 431.1 ± 130.7 PH 7.38 ± 0.04 7.26 ± 0.06 * 7.30 ± 0.04 * 7.34 ± 0.03 * PaCO 2 41.5 ± 4.0 59.2 ± 8.3 * 52.5 ± 4.5 * 46.9 ± 5.1 * Lac 1.25 ± 0.34 1.26 ± 0.34 1.27 ± 0.35 1.29 ± 0.35 *Compared with 5 minutes before inflation (P < 0.05). HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; PeakAP: peak airway pressure; ETCO 2 : end-expiratory carbon dioxide partial pressure; TV: tidal volume; OI: oxygenation index; PaCO 2 : carbon dioxide partial pressure; Lac: lactic acid level. The changes in HR, MAP, and CVP are shown in Fig. 1 (A-C) respectively. HR, MAP and CVP increased immediately after inflation and exhibited no significant change during inflation; however, these values also decreased significantly after gas shutdown, although they did not return to the baseline value. When the mediastinal pressure was 10 mmHg and the pneumoperitoneum pressure was 12 mmHg, the average increase in HR was 16.5 bpm, the average increase in MAP was 18.6 mmHg, and the average increase in CVP was 8.2 cmH2O. The changes in Peak AP, ETCO 2 , OI, PH, and PaCO 2 are shown in Fig. 2 (A-E) respectively. Peak AP increased immediately after inflation (Fig. 2 A). The average value of Peak AP was 22.8 cmH 2 O during inflation, with a mean increase of 7.4 cmH 2 O (P < 0.05) 5 minutes after inflation. The average ETCO2 of 6.2 cmH 2 O (P < 0.05) increased 5 minutes after inflation (Fig. 2 B), and the average value of ETCO 2 was 41.0 mmHg during inflation. Compared with the baseline value, the TV decreased significantly at 1 hour after inflation (P < 0.05). The OI decreased sharply at 1 hour after inflation, with an average decrease of 158.6, gradually returning to close to the baseline value after gas shutdown. PaCO 2 increased 17.7 mmHg on average at 1 hour after inflation. However, there was no significant change in the blood-gas lactic acid level before and after inflation (P = NS). The incidence of postoperative complications is shown in Table 3 . 90-day mortality was 0. Anastomotic fistula occurred in 9 cases (8.6%), which were cured after vacuum sealing drainage (VSD) or routine drainage and adequate nutrition treatment. Among them, 9 cases (8.6%) required management of pleural effusion, and all of these cases were treated by indwelling thoracic tube drainage. Postoperative chylous leakage occurred in 1 case (0.9%). Approximately 300–400 ml of a chylous fluid was drained. Enteral nutrition was stopped and then restored following parenteral nutrition and adequate drainage. Postoperative atelectasis occurred in 0 cases. Postoperative Pneumonia occurred in 8 cases (7.6%), which could be cured by anti-infective treatment. Arrhythmia occurred in 4 cases (3.8%). Hoarseness was caused by recurrent laryngeal nerve injury in 19 cases (18.2%); however, such injury of the recurrent laryngeal nerve was temporary and reversible. Voice training and an intravenous drip of ganglioside 40 mg/d were used for 3 days, and the patients gradually recovered within 1 to 2 months. Only 5 patients still had hoarseness 3 months after the operation. The visual analog scale (VAS) score of all patients in the first 3 days after operation was 4.09 ± 0.57. Table 3 Perioperative observation index Parameters Quantity (%) Blood loss (ml) 113.4 ± 89.9 - operative time(min) 186.7 ± 43.9 - Conversion to thoracotomy 1 0.9 Postoperative hospital stay 18.6 ± 8.0 - R0 resection The 90-day mortality - 0 100 0 Lymph node dissection 22.5 ± 4.5 - Complication - - Anastomotic fistula 9 8.6 Pleural effusion that needs to be treated 9 8.6 Chylothorax 1 0.9 Atelectasis 0 0 Pneumonia Arrhythmia 8 4 7.6 3.8 hoarseness 19 18.2 Hoarseness at 3 months postoperatively 5 4.8 Discussion Transthoracic esophagectomy has become the standard procedure for EC because it enables extensive mediastinal lymphadenectomy 18 – 20 . However, postoperative pulmonary complications are a major problem in transthoracic surgery and the main cause of morbidity and mortality after thoracic surgery 21 . Non-transthoracic surgery, such as THE, is another option for MIE. Single-port mediastinoscopy-assisted transesophageal hiatal esophagectomy, which was developed by Fujiwara et al., has the advantages of less potential blood loss, a shorter operative time, and fewer cardiopulmonary complications 22 . Our team improved the procedure, which was administered to two groups at the same time, and the operative time was obviously shortened. Ye et al. conducted a retrospective comparative study and suggested that left recurrent laryngeal lymph node dissection is still a major technical challenge in MIE 20 . As we previously reported 15 , we entered the mediastinum through the cervical incision, inflated it to form a mediastinal cavity, and easily cleared the lymph nodes along the left recurrent laryngeal nerve while also completely clearing the subcarinal lymph nodes. A retrospective study reported that the incidence of pneumonia and arrhythmia after transthoracic minimally invasive esophagectomy was 12.4% and 14%, respectively 23 . In this study, we had a low incidence of postoperative pneumonia and arrhythmias. In this study, we inflated the mediastinum and abdomen at the same time to provide a clear surgical field of vision (Fig. 3 ). Our average operative time was 240.7 minutes, and the average intraoperative blood loss was 113.4 ml. Compared with thoracoabdominal endoscopy or traditional transthoracic open esophagectomy, our procedure reduced the operative and blood loss 24 . A retrospective study comparing one-lung ventilation and two-lung ventilation during MIE showed that the incidence of hypoxemia in the two-lung ventilation group was significantly lower than that in the one-lung ventilation group 25 . In our study, single-lumen endotracheal intubation was also used, but CO 2 gas was filled into the mediastinum and abdomen simultaneously. Pneumoperitoneum and mediastinal emphysema, intraabdominal pressure, and CO 2 absorption into the blood may cause a series of pathophysiological changes, affecting the respiratory and circulatory function of the patients and leading to postoperative cardiopulmonary complications. CO 2 can increase the intra-abdominal and mediastinal pressures, elevate the diaphragm and compress the parietal pleura, thereby reducing lung compliance and increasing airway pressure, thus changing the pulmonary ventilation function and affecting intraoperative respiratory function 26 , 27 . Hypercapnia occurs after CO 2 is absorbed into the blood and can induce a series of stress responses (such as stimulation of the sympathetic nervous system and the release of catecholamines), stimulate the cardiovascular system, and cause an increase in arterial pressure 28 . Secondly, increased intra-abdominal pressure and mediastinal pressure can compress large blood vessels, reduce venous reflux, increase systemic vascular resistance and increase CVP. At the same time, cardiac output is reduced, and the reflex causes sympathetic nerve excitation, which eventually increases arterial pressure and then affects circulatory function during the operation 28 . This study was a retrospective study of 104 patients who successfully completed SPIMSLE. During the operation, CO 2 was infused into the mediastinum with a mediastinal pressure of 10 mmHg and an intraperitoneal pressure of 12 mmHg. The HR, MAP and CVP increased significantly after inflation, but the values did not fluctuate and were within a safe and acceptable range during the inflation stage and gradually returned to the pre-inflation state after gas closure. No hypoxemia or respiratory inhibition was observed throughout the entire. After CO 2 inflation, pH decreased, while PaCO 2 , peak AP and ETCO 2 increased significantly after inflation, but these changes did not last long and returned to the normal level after the removal of CO 2 . Although PaCO 2 increased significantly during the operation, the vital signs of most patients were stable, and there was no significant change in blood lactic acid levels, except for 2 patients who required adjustment in respiratory parameters to correct the elevated PaCO 2 . Currently, there is no clear definition of the acceptable elevation of PaCO 2 in the clinic, so it is necessary to make a comprehensive judgment that also considers the vital signs of the patients. Although the OI decreased after inflation, it was still within a safe and acceptable range. With the deepening of the upper mediastinum and the lower mediastinum during the operation, the space of the operation was narrow, so it was necessary to control the effect of bilateral lung respiration on the mediastinal operation; moreover, the TV was artificially adjusted, so there was a significant difference between the TV at one hour after inflation and the baseline TV value. When dissociating the middle and lower esophagus during the operation, the lower mediastinal retractor should be used to lift the heart. In the study, 5 patients had hypotension or frequent premature ventricular contractions, which led to suspension of the operation. Notably, after waiting for a few minutes, the patients could continue the operation after their vital signs were stable. Therefore, when the mediastinal pressure and pneumoperitoneum pressure are 10 mmHg and 12 mmHg, respectively, this can provide a clear operative field and sufficient operating space, and the operation is safe under standard operation conditions. Minimally invasive surgery should be the first choice for patients with EC. Compared with MIE via a transthoracic approach, THE is considered to be less invasive and more tolerable, especially in patients with severe complications 9 , 29 . However, when the patient has comorbid diseases, such as severe chest adhesions, chest deformities, poor cardiopulmonary function, poor tolerance of one-lung ventilation, or a history of major right lung surgery 15 , 30 , transthoracic MIE is very difficult for surgeons and patients, and SPIMSLE may be a better choice. In this study, we successfully completed the operation in 104 patients, there was no perioperative death, and the postoperative pathology confirmed that the R0 resection rate was 100%. The incidence of postoperative anastomotic fistula was similar to that of MIE via the transthoracic approach (5.0 ~ 12%) 4 , 31 . Compared with minimally invasive transthoracic esophagectomy 4 , the incidence of postoperative hoarseness is still higher and needs to be improved There are still some limitations of this study. First, this study was retrospective, and we did not include patients with other EC operations as a control group. In subsequent research, a well-designed randomized controlled trial should be conducted to comprehensively evaluate the efficacy and safety of this new surgical method. Second, we did not evaluate the long-term quality of life of the patients after surgery. All these limitations should be addressed in future studies. Conclusion When the inflation pressures in the mediastinum and abdomen were 10 mmHg and 12 mmHg, respectively, we safely completed surgery without respiratory and circulatory inhibition. In summary, our results show that our single-port inflatable mediastinoscopy with simultaneous laparoscopic radical resection of EC is technically safe and does not increase perioperative complications. Abbreviations EC : Esophageal cancer MIE : minimally invasive esophagectomy THE : Transhiatal esophagectomy SPIMSLE : single-port inflatable mediastinoscopy simultaneous laparoscopic radical esophagectomy CVP : central venous pressure CO2 : carbon dioxide HR :Heart rate MAP : mean arterial pressure peak AP: peak airway pressure ETCO2: end-expiratory CO2 partial pressure FiO2: inhaled oxygen concentration TV : tidal volume OI : oxygenation index VSD : vacuum sealing drainage VAS : visual analog scale Declarations Ethics approval and consent to participate ： The hospital ethics committee approval was granted of this article. Consent for publication was obtained from the paitent. Consent for publication: Written informed consent was obtained from the patients for publication of this article. Availability of data and materials ： The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: All authors declare that they have no competing interests. Funding: This study was supported by the Talents start-up funding of Sun Yat-sen University and National Key Research and Development Program of China (2018YFC0910600). Authors' contributions: Haibo Ye and Xiaojin Wang: drafting and revising manuscript. Xiaojian Li: acquisition. Xiangfeng Gan: analysis.Hongcheng Zhong: interpretation of data. Qingdong Cao and Xiangwen Wu: design and approval. Acknowledgements: Not applicable. References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 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Asian J Endosc Surg. 2019 Jan;12(1):30–6. PubMed PMID: 30681280. Epub 2019/01/27. Ben-David K, Tuttle R, Kukar M, Rossidis G, Hochwald SN. Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population. Ann Surg Oncol. 2016 Sep;23(9):3056–62. PubMed PMID: 27112585. Epub 2016/04/27. eng. Kanekiyo S, Takeda S, Tsutsui M, Nishiyama M, Kitahara M, Shindo Y, et al. Low invasiveness of thoracoscopic esophagectomy in the prone position for esophageal cancer: a propensity score-matched comparison of operative approaches between thoracoscopic and open esophagectomy. Surg Endosc. 2018 Apr;32(4):1945–53. PubMed PMID: 29075967. Epub 2017/10/28. eng. Lin M, Shen Y, Wang H, Fang Y, Qian C, Xu S, et al. A comparison between two lung ventilation with CO2 artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy. J Thorac Dis. 2018 Mar;10(3):1912–8. PubMed PMID: 29707346. Pubmed Central PMCID: PMC5906341. Epub 2018/05/01. Nguyen NT, Anderson JT, Budd M, Fleming NW, Ho HS, Jahr J, et al. Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass. Surg Endosc. 2004 Jan;18(1):64–71. PubMed PMID: 14625752. Epub 2003/11/20. eng. Romero KJ, Trujillo MH. Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: The Macklin effect. Heart Lung. 2010 Sep-Oct;39(5):444-7. PubMed PMID: 20561891. Epub 2010/06/22. eng. Barczynski M, Herman RM. Influence of different pressures of pneumoperitoneum on the autonomic system function during laparoscopy. Folia Med Cracov. 2002;43(1–2):51 – 8. PubMed PMID: 12815798. Epub 2003/06/21. eng.. Namm JP, Posner MC. Transhiatal Esophagectomy for Esophageal Cancer. J Laparoendosc Adv Surg Tech A. 2016 Oct;26(10):752–6. PubMed PMID: 27548444. Epub 2016/08/23. Peng JS, Kukar M, Mann GN, Hochwald SN. Minimally Invasive Esophageal Cancer Surgery. Surg Oncol Clin N Am. 2019 Apr;28(2):177–200. PubMed PMID: 30851822. Epub 2019/03/11. Biere SSAY, van Berge Henegouwen MI, Maas KW, Bonavina L, Rosman C, Garcia JR, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. The Lancet. 2012;379(9829):1887–92. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Minor revision 11 Aug, 2021 Review # 2 received at journal 06 Aug, 2021 Review # 1 received at journal 04 Aug, 2021 Reviewer # 2 agreed at journal 23 Jul, 2021 Reviews received at journal 21 Jul, 2021 Reviewers invited by journal 20 Jul, 2021 Reviewer # 1 agreed at journal 20 Jul, 2021 Editor assigned by journal 20 Jun, 2021 Submission checks completed at journal 20 Jun, 2021 Editor invited by journal 20 Jun, 2021 First submitted to journal 20 Jun, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-642915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":35692285,"identity":"ec0d756e-a02e-4f5f-94a3-79d50872c42a","order_by":0,"name":"Haibo Ye","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Ye","suffix":""},{"id":35692286,"identity":"6f3b4814-449d-4f68-803d-28263387dabe","order_by":1,"name":"Xiaojin Wang","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaojin","middleName":"","lastName":"Wang","suffix":""},{"id":35692287,"identity":"bda443d2-62ff-476d-99f1-7ef6f876f3f0","order_by":2,"name":"Xiaojian Li","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaojian","middleName":"","lastName":"Li","suffix":""},{"id":35692288,"identity":"6398a603-dbc3-4c3d-b2eb-c2b471dc203c","order_by":3,"name":"Xiangfeng Gan","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiangfeng","middleName":"","lastName":"Gan","suffix":""},{"id":35692289,"identity":"f2dbfb38-2c9b-4273-a4ca-e5eac3bc199a","order_by":4,"name":"Hongcheng Zhong","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hongcheng","middleName":"","lastName":"Zhong","suffix":""},{"id":35692290,"identity":"7235ef57-62ef-4a8b-8c70-d1d80e7e4c0f","order_by":5,"name":"Xiangwen Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABB0lEQVRIiWNgGAWjYFACHjbmHxUMDGzszAdgQgaEtTCcAWphZksgQQtjG5Bm5oGrxK/F4HjvsceF87bJ8zEzGDD+bKtLbGBv3ibBUHMHt5Yz59KNZ267bdjGzJDAzNt2OLGB51iZBMOxZ7i13Mgxk+DddpsRqOUA0IUHEhskgCKMDYdxa7n/Bqhlzm37NmbGBojD5N8Q0HKDx0yat+F2YhszMwMDbxsz0BYe/Fokz+SYG844dju5jZmN4TDPucPGbTxpxRYJx3Br4Tt+xuzBh5rbtvPb+z8+/FFWJ9vPfnjjjQ81uLUoHEDiHGBkA8YpiJWAUwMDg3wDCvcPHqWjYBSMglEwYgEAghZTy8+AusYAAAAASUVORK5CYII=","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Xiangwen","middleName":"","lastName":"Wu","suffix":""},{"id":35692291,"identity":"00ca1444-9175-440a-b821-8a93f8fb4e0a","order_by":6,"name":"Qingdong Cao","email":"","orcid":"","institution":"Fifth Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qingdong","middleName":"","lastName":"Cao","suffix":""}],"badges":[],"createdAt":"2021-06-20 18:59:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-642915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-642915/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":10923405,"identity":"ac5114b9-d7dc-4781-b0bd-5fa793a1c40d","added_by":"auto","created_at":"2021-06-29 19:36:18","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":291600,"visible":true,"origin":"","legend":"Changes in circulatory parameters after intraoperative inflation. 5min, 10min, 20min, 1h are the post-inflatable time period. (A), (B) and (C) showed the intraoperative changes of HR, MAP and CVP, respectively. HR, MAP and CVP increased significantly after aeration, and decreased steadily after gas shutdown.","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-642915/v1/f61e08464c879933a12dcc28.jpg"},{"id":10923406,"identity":"1bc81904-df72-4299-a0b2-d3832a9abcac","added_by":"auto","created_at":"2021-06-29 19:36:18","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":245024,"visible":true,"origin":"","legend":"Changes of respiratory parameters after inflation during operation. 5min, 10min, 20min, 1h are the post-inflatable time period. (A), (B), (C), (D) and (E) showed the intraoperative changes of Peak AP, ETCO2, OI, PH and PaCO2, respectively. After inflation, Peak AP, ETCO2 and PaCO2 increased significantly, while OI and PH decreased significantly. The baseline level can be gradually restored after gas shutdown.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-642915/v1/27b584bf2b0182ebe650df8c.jpg"},{"id":10924146,"identity":"ab7f4bde-b315-4d69-a575-be481689a578","added_by":"auto","created_at":"2021-06-29 19:39:18","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":320118,"visible":true,"origin":"","legend":"Intraoperative Visual field after inflation. (A) Transcervical view in the upper mediastinum in the artificial emphysema. (B) Transcervical view when the upper and lower mediastinum penetrates.","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-642915/v1/5f0f9e5827fc7ca6edf90b9e.jpg"},{"id":13701500,"identity":"8482e321-4851-4aab-928a-31be718120d3","added_by":"auto","created_at":"2021-09-17 13:30:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":504591,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-642915/v1/f184caf0-d38f-4446-8945-66f1bfdf997a.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eEffect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy On Respiration and Circulation\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eEsophageal cancer (EC) is one of the most common malignant tumors in the world, ranking seventh in global morbidity and sixth in mortality \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The prognosis of EC is poor, and the 5-year survival rate is less than 25% \u003csup\u003e2\u003c/sup\u003e. Currently, the basic treatment strategy for EC is a combination of surgery, radiotherapy and chemotherapy, and surgical treatment is still the main and preferred treatment \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Previous studies have shown that compared with open esophagectomy, minimally invasive esophagectomy (MIE) has the advantages of less postoperative pain, less intraoperative bleeding, shorter hospital stay and recovery time, and more extensive lymph node dissection. Thus, MIE has become the preferred surgical method \u003csup\u003e\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe approaches of MIE are transthoracic and non-transthoracic (e.g., transhiatal esophagectomy). Transhiatal esophagectomy (THE) is considered to be less invasive and has fewer pulmonary complications because it avoids thoracotomy \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. However, traditional THE has more stringent surgical indications because of its limited field of vision and insufficient mediastinal lymph node dissection, which is more suitable for cancers that indicate negative lymph nodes, and the oncology results are usually considered poor \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. To overcome this shortcoming, Fujiwara et al developed a new surgical method, namely, a radical resection of thoracic EC by using inflatable mediastinoscopic lymph node dissection through cervical incisions and hand-assisted laparoscopic lymph node dissection of the upper mediastinum, and this method has been reported to be safe and feasible\u003csup\u003e\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. On this basis, our organization further improved the operation and carried out single-port inflatable mediastinoscopy simultaneous laparoscopic radical esophagectomy (SPIMSLE) \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e .Our team improved this operation as following differences: first, our team is divided into mediastinal group and abdominal group to operate at the same time, and the operation time is significantly shortened; second, our abdominal group is operated completely under laparoscopy. rather than hand-assisted laparoscopic surgery, the trauma is less. Third, we have performed lymph node dissection of the right vagus nerve and the right recurrent laryngeal nerve through the left cervical incision\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this procedure, we inflated the mediastinum and abdomen to provide a clear field of view for esophagectomy and mediastinal lymph node dissection. This operation, which is a relatively new surgical method, is not performed through the chest or one-lung ventilation and causes less damage to the lungs. Whether simultaneous inflation of the mediastinum and abdomen during surgery has a significant impact on the respiratory and circulatory systems has not been reported. The purpose of this study was to evaluate the perioperative safety of this procedure.\u003c/p\u003e "},{"header":"Materials And Methods","content":" \u003cp\u003eFrom April 2018 to October 2020, patients with esophageal malignant tumors were treated with SPIMSLE in the Fifth Affiliated Hospital of Sun Yat-sen University. The inclusion criteria were as follows: (1) pathologically confirmed malignant tumor and The preoperative T stages were T1b-T3 ; (2) functional tolerance of major organs and systems for radical surgery; (3) no other cancers; (4) no history of mediastinal surgery; The exclusion criteria were as follows: (1) cervical EC;(2) refusal of surgery.\u003c/p\u003e \u003cp\u003e This study was approved by the institutional review committee of our hospital. Written informed consent was obtained from each patient.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAnesthesia\u003c/b\u003e: Preoperative medication included intramuscular injection of atropine 0.01mg/kg. Anesthesia was induced by intravenous injection of midazolam 0.05mg/Kg, propofol 2mg/kg, muscle relaxant cis atracurium 0.15\u0026thinsp;~\u0026thinsp;0.25mg/kg and sufentanil citrate 0.1-0.3ug/Kg. Insert 7/7.5-FR single lumen catheter (Sheridan endotracheal catheter, Sher-I-Bronch). Do not use bronchial blockers. Mechanical ventilation after intubation (tidal volume 6\u0026ndash;8 ml / kg; inspiratory time / expiratory time ratio: 1 / 1.5). Adjust the respiratory rate and do not use positive end-expiratory pressure. Anesthesia was maintained by continuous intravenous infusion of remifentanil 0.25g -1.0g / kg / min, while inhaling air, oxygen and sevoflurane. After operation, the tube was extubated after the recovery of pharynx reflex, inhalation and ventilation. All intubation procedures are performed by experienced anesthesiologists.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSurgical Procedure\u003c/strong\u003e \u003cp\u003eThe patients were ventilated with single-lumen endotracheal intubation under general anesthesia in the supine position; central venous pressure (CVP) was recorded by a central venous catheter in the right subclavian vein; and blood pressure was monitored by an indwelling arterial catheter in the right radial artery. The operation was performed by two groups of people through the cervical incision via the mediastinoscope and the abdomen via the laparoscope at the same time, and the surgical incision and surgeon's location were performed as described in our recent report \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe operation in the mediastinal group was performed as follows: first, access was gained through the cervical incision, and the cervical esophagus was freed, establishing a tunnel filled with carbon dioxide (CO\u003csub\u003e2\u003c/sub\u003e) gas to create artificial mediastinal emphysema and obtaining a pressure of 10 mmHg. After we methodically tried various pressure gradients, when the mediastinal pressure was 10 mmHg, the operative field was clear, and the operative space was wide. Second, we continued to dissociate the upper and middle thoracic esophagus and dissected the lymph nodes in the thoracic region.\u003c/p\u003e \u003cp\u003eThe operation in the abdomen group was performed as follows: the artificial pneumoperitoneum pressure was 12 mmHg, which is the conventional laparoscopic operative pressure. The stomach was dissociated, and the lymph nodes in the abdominal region of the esophagus were dissected. Next, the lower thoracic esophagus was dissociated through the diaphragmatic esophageal hiatus, and the surrounding lymph nodes were cleared. Finally, it penetrated the superior mediastinum. The air source was turned off, and inflation was stopped.\u003c/p\u003e \u003cp\u003eThe esophagus was incised at the neck, the Tubular stomach was created, and the neck was anastomosed with the proximal esophagus through the esophageal bed. The neck and abdominal incisions were sutured.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObservation Parameters\u003c/b\u003e: Heart rate (HR), invasive mean arterial pressure (MAP), central venous pressure (CVP), peak airway pressure (AP), end-expiratory CO\u003csub\u003e2\u003c/sub\u003e partial pressure (ETCO\u003csub\u003e2\u003c/sub\u003e), inhaled oxygen concentration (FiO\u003csub\u003e2\u003c/sub\u003e) and tidal volume (TV) were continuously monitored and recorded during the operation. Arterial blood samples were collected for blood gas analysis at the following time points: 5 minutes before inflation of the mediastinum and abdomen (baseline); 1 hour after inflation; 20 minutes after CO\u003csub\u003e2\u003c/sub\u003e excretion; and 10 minutes after the operation. These data were collected from anesthetic records. At the same time, the operative duration, amount of bleeding, and A special event during the operation were recorded. Postoperative pathological data, postoperative complications, and postoperative hospital stay information were collected.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003eContinuous data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). The classified data are expressed as a percentage. During the operation, taking the pre-inflation data as the reference, the Welch test was used to analyze the numerical difference in each period after inflation. All statistical analyses were conducted using IBM SPSS version 25 (SPSS Statistics v25, IBM, Somers, NY, USA). When P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, the result was considered significant.\u003c/p\u003e \u003c/p\u003e "},{"header":"Results","content":" \u003cp\u003eA total of 105 patients who underwent SPIMSLE from April 2018 to October 2020 were enrolled. The demographic and clinical characteristics of the 105 patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The average age was 62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 years (range 42\u0026ndash;84 years), the percentage of vital capacity (VC) was 70.5-176.1% (101.68\u0026thinsp;\u0026plusmn;\u0026thinsp;23.00%), the percentage of forced expiratory volume to predicted value within 1 s (FEV1%) was 67.9-163.3% (100.05\u0026thinsp;\u0026plusmn;\u0026thinsp;20.80%), and the average cardiac ejection fraction was 69.35\u0026thinsp;\u0026plusmn;\u0026thinsp;5.11. The tumor sites included the upper chest (n\u0026thinsp;=\u0026thinsp;14), middle chest (n\u0026thinsp;=\u0026thinsp;56) and lower chest (n\u0026thinsp;=\u0026thinsp;35). The preoperative T stages were as follows: T1b, 36 patients; T2, 49patients; and T3, 20 patients. Comorbidities included COPD (n\u0026thinsp;=\u0026thinsp;6), hypertension (n\u0026thinsp;=\u0026thinsp;27) and diabetes (n\u0026thinsp;=\u0026thinsp;9). Twenty-one of these patients received neoadjuvant chemotherapy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics and clinical characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.6(42\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUpper thoracic segment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLower thoracic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiopsy pathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSarcomatoid carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuroendocrine Carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe preoperative T stages\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCOPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeoadjuvant Chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeoadjuvant radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntraoperative observation index\u003c/p\u003e \u003cp\u003eThere were no deaths within 30 days postoperatively. A total of 104 patients underwent SPIMSLE, and 1 patient underwent thoracotomy because of tracheal membrane injury during mediastinoscopy. Pleural rupture occurred in 5 cases, and the airway pressure increased immediately after pleural rupture, up to 4 cmH\u003csub\u003e2\u003c/sub\u003eO. The effect of tension pneumothorax on the operation could be avoided by suspending the operation for several minutes, properly reducing tidal volume and enlarging the scope of rupture. The average operative time was 186.7\u0026thinsp;\u0026plusmn;\u0026thinsp;43.9 minutes, and the average intraoperative blood loss was 113.4\u0026thinsp;\u0026plusmn;\u0026thinsp;89.9 ml. The field of view was clear during the operation, and the average number of lymph nodes dissected was 22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5.\u003c/p\u003e \u003cp\u003eDuring the operation, the hemodynamics and respiratory movement indexes of 104 cases were monitored when CO\u003csub\u003e2\u003c/sub\u003e was inflated into the mediastinum and abdomen synchronously, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The data from 5 minutes before CO\u003csub\u003e2\u003c/sub\u003e inflation were taken as the baseline, and there were significant differences in HR, MAP, CVP, Peak AP, ETCO\u003csub\u003e2\u003c/sub\u003e, PH, oxygenation index (OI, the ratio of inhaled oxygen concentration to the partial pressure of oxygen) and partial pressure of CO\u003csub\u003e2\u003c/sub\u003e (PaCO\u003csub\u003e2\u003c/sub\u003e) after inflation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in the respiratory and circulatory systems before and after inflation intraoperatively.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eInflatable stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 min before inflation (baseline)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 min after gas shutdown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePostoperative 10 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e90.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e77.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e73.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103.4\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e104.3\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e90.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e97.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeak AP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eETCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e403.2\u0026thinsp;\u0026plusmn;\u0026thinsp;51.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e395.6\u0026thinsp;\u0026plusmn;\u0026thinsp;49.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e378.6\u0026thinsp;\u0026plusmn;\u0026thinsp;70.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e379.5\u0026thinsp;\u0026plusmn;\u0026thinsp;50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e354.9\u0026thinsp;\u0026plusmn;\u0026thinsp;41.9\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e365.8\u0026thinsp;\u0026plusmn;\u0026thinsp;42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e377.6\u0026thinsp;\u0026plusmn;\u0026thinsp;43.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e474.6\u0026thinsp;\u0026plusmn;\u0026thinsp;71.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e316.2\u0026thinsp;\u0026plusmn;\u0026thinsp;94.6\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e360.6\u0026thinsp;\u0026plusmn;\u0026thinsp;80.1\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e431.1\u0026thinsp;\u0026plusmn;\u0026thinsp;130.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e52.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e46.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 \u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Compared with 5 minutes before inflation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). HR: heart rate; MAP: mean arterial pressure; CVP: central venous pressure; PeakAP: peak airway pressure; ETCO\u003csub\u003e2\u003c/sub\u003e: end-expiratory carbon dioxide partial pressure; TV: tidal volume; OI: oxygenation index; PaCO\u003csub\u003e2\u003c/sub\u003e: carbon dioxide partial pressure; Lac: lactic acid level.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe changes in HR, MAP, and CVP are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (A-C) respectively. HR, MAP and CVP increased immediately after inflation and exhibited no significant change during inflation; however, these values also decreased significantly after gas shutdown, although they did not return to the baseline value. When the mediastinal pressure was 10 mmHg and the pneumoperitoneum pressure was 12 mmHg, the average increase in HR was 16.5 bpm, the average increase in MAP was 18.6 mmHg, and the average increase in CVP was 8.2 cmH2O.\u003c/p\u003e\u003cp\u003eThe changes in Peak AP, ETCO\u003csub\u003e2\u003c/sub\u003e, OI, PH, and PaCO\u003csub\u003e2\u003c/sub\u003e are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (A-E) respectively. Peak AP increased immediately after inflation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The average value of Peak AP was 22.8 cmH\u003csub\u003e2\u003c/sub\u003eO during inflation, with a mean increase of 7.4 cmH\u003csub\u003e2\u003c/sub\u003eO (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) 5 minutes after inflation. The average ETCO2 of 6.2 cmH\u003csub\u003e2\u003c/sub\u003eO (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) increased 5 minutes after inflation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB), and the average value of ETCO\u003csub\u003e2\u003c/sub\u003e was 41.0 mmHg during inflation. Compared with the baseline value, the TV decreased significantly at 1 hour after inflation (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The OI decreased sharply at 1 hour after inflation, with an average decrease of 158.6, gradually returning to close to the baseline value after gas shutdown. PaCO\u003csub\u003e2\u003c/sub\u003e increased 17.7 mmHg on average at 1 hour after inflation. However, there was no significant change in the blood-gas lactic acid level before and after inflation (P\u0026thinsp;=\u0026thinsp;NS).\u003c/p\u003e\u003cp\u003eThe incidence of postoperative complications is shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. 90-day mortality was 0. Anastomotic fistula occurred in 9 cases (8.6%), which were cured after vacuum sealing drainage (VSD) or routine drainage and adequate nutrition treatment. Among them, 9 cases (8.6%) required management of pleural effusion, and all of these cases were treated by indwelling thoracic tube drainage. Postoperative chylous leakage occurred in 1 case (0.9%). Approximately 300\u0026ndash;400 ml of a chylous fluid was drained. Enteral nutrition was stopped and then restored following parenteral nutrition and adequate drainage. Postoperative atelectasis occurred in 0 cases. Postoperative Pneumonia occurred in 8 cases (7.6%), which could be cured by anti-infective treatment. Arrhythmia occurred in 4 cases (3.8%). Hoarseness was caused by recurrent laryngeal nerve injury in 19 cases (18.2%); however, such injury of the recurrent laryngeal nerve was temporary and reversible. Voice training and an intravenous drip of ganglioside 40 mg/d were used for 3 days, and the patients gradually recovered within 1 to 2 months. Only 5 patients still had hoarseness 3 months after the operation. The visual analog scale (VAS) score of all patients in the first 3 days after operation was 4.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative observation index\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuantity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113.4\u0026thinsp;\u0026plusmn;\u0026thinsp;89.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eoperative time(min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186.7\u0026thinsp;\u0026plusmn;\u0026thinsp;43.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConversion to thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0 resection\u003c/p\u003e \u003cp\u003eThe 90-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph node dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnastomotic fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion that needs to be treated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChylothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtelectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003cp\u003eArrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehoarseness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHoarseness at 3 months postoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eTransthoracic esophagectomy has become the standard procedure for EC because it enables extensive mediastinal lymphadenectomy \u003csup\u003e\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, postoperative pulmonary complications are a major problem in transthoracic surgery and the main cause of morbidity and mortality after thoracic surgery \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Non-transthoracic surgery, such as THE, is another option for MIE. Single-port mediastinoscopy-assisted transesophageal hiatal esophagectomy, which was developed by Fujiwara et al., has the advantages of less potential blood loss, a shorter operative time, and fewer cardiopulmonary complications\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Our team improved the procedure, which was administered to two groups at the same time, and the operative time was obviously shortened. Ye et al. conducted a retrospective comparative study and suggested that left recurrent laryngeal lymph node dissection is still a major technical challenge in MIE\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. As we previously reported \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, we entered the mediastinum through the cervical incision, inflated it to form a mediastinal cavity, and easily cleared the lymph nodes along the left recurrent laryngeal nerve while also completely clearing the subcarinal lymph nodes. A retrospective study reported that the incidence of pneumonia and arrhythmia after transthoracic minimally invasive esophagectomy was 12.4% and 14%, respectively\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In this study, we had a low incidence of postoperative pneumonia and arrhythmias.\u003c/p\u003e \u003cp\u003eIn this study, we inflated the mediastinum and abdomen at the same time to provide a clear surgical field of vision (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Our average operative time was 240.7 minutes, and the average intraoperative blood loss was 113.4 ml. Compared with thoracoabdominal endoscopy or traditional transthoracic open esophagectomy, our procedure reduced the operative and blood loss\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. A retrospective study comparing one-lung ventilation and two-lung ventilation during MIE showed that the incidence of hypoxemia in the two-lung ventilation group was significantly lower than that in the one-lung ventilation group \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In our study, single-lumen endotracheal intubation was also used, but CO\u003csub\u003e2\u003c/sub\u003e gas was filled into the mediastinum and abdomen simultaneously. Pneumoperitoneum and mediastinal emphysema, intraabdominal pressure, and CO\u003csub\u003e2\u003c/sub\u003e absorption into the blood may cause a series of pathophysiological changes, affecting the respiratory and circulatory function of the patients and leading to postoperative cardiopulmonary complications. CO\u003csub\u003e2\u003c/sub\u003e can increase the intra-abdominal and mediastinal pressures, elevate the diaphragm and compress the parietal pleura, thereby reducing lung compliance and increasing airway pressure, thus changing the pulmonary ventilation function and affecting intraoperative respiratory function\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Hypercapnia occurs after CO\u003csub\u003e2\u003c/sub\u003e is absorbed into the blood and can induce a series of stress responses (such as stimulation of the sympathetic nervous system and the release of catecholamines), stimulate the cardiovascular system, and cause an increase in arterial pressure \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Secondly, increased intra-abdominal pressure and mediastinal pressure can compress large blood vessels, reduce venous reflux, increase systemic vascular resistance and increase CVP. At the same time, cardiac output is reduced, and the reflex causes sympathetic nerve excitation, which eventually increases arterial pressure and then affects circulatory function during the operation \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study was a retrospective study of 104 patients who successfully completed SPIMSLE. During the operation, CO\u003csub\u003e2\u003c/sub\u003e was infused into the mediastinum with a mediastinal pressure of 10 mmHg and an intraperitoneal pressure of 12 mmHg. The HR, MAP and CVP increased significantly after inflation, but the values did not fluctuate and were within a safe and acceptable range during the inflation stage and gradually returned to the pre-inflation state after gas closure. No hypoxemia or respiratory inhibition was observed throughout the entire. After CO\u003csub\u003e2\u003c/sub\u003e inflation, pH decreased, while PaCO\u003csub\u003e2\u003c/sub\u003e, peak AP and ETCO\u003csub\u003e2\u003c/sub\u003e increased significantly after inflation, but these changes did not last long and returned to the normal level after the removal of CO\u003csub\u003e2\u003c/sub\u003e. Although PaCO\u003csub\u003e2\u003c/sub\u003e increased significantly during the operation, the vital signs of most patients were stable, and there was no significant change in blood lactic acid levels, except for 2 patients who required adjustment in respiratory parameters to correct the elevated PaCO\u003csub\u003e2\u003c/sub\u003e. Currently, there is no clear definition of the acceptable elevation of PaCO\u003csub\u003e2\u003c/sub\u003e in the clinic, so it is necessary to make a comprehensive judgment that also considers the vital signs of the patients. Although the OI decreased after inflation, it was still within a safe and acceptable range. With the deepening of the upper mediastinum and the lower mediastinum during the operation, the space of the operation was narrow, so it was necessary to control the effect of bilateral lung respiration on the mediastinal operation; moreover, the TV was artificially adjusted, so there was a significant difference between the TV at one hour after inflation and the baseline TV value. When dissociating the middle and lower esophagus during the operation, the lower mediastinal retractor should be used to lift the heart. In the study, 5 patients had hypotension or frequent premature ventricular contractions, which led to suspension of the operation. Notably, after waiting for a few minutes, the patients could continue the operation after their vital signs were stable. Therefore, when the mediastinal pressure and pneumoperitoneum pressure are 10 mmHg and 12 mmHg, respectively, this can provide a clear operative field and sufficient operating space, and the operation is safe under standard operation conditions.\u003c/p\u003e \u003cp\u003eMinimally invasive surgery should be the first choice for patients with EC. Compared with MIE via a transthoracic approach, THE is considered to be less invasive and more tolerable, especially in patients with severe complications \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. However, when the patient has comorbid diseases, such as severe chest adhesions, chest deformities, poor cardiopulmonary function, poor tolerance of one-lung ventilation, or a history of major right lung surgery \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e, transthoracic MIE is very difficult for surgeons and patients, and SPIMSLE may be a better choice.\u003c/p\u003e \u003cp\u003eIn this study, we successfully completed the operation in 104 patients, there was no perioperative death, and the postoperative pathology confirmed that the R0 resection rate was 100%. The incidence of postoperative anastomotic fistula was similar to that of MIE via the transthoracic approach (5.0\u0026thinsp;~\u0026thinsp;12%) \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Compared with minimally invasive transthoracic esophagectomy \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, the incidence of postoperative hoarseness is still higher and needs to be improved There are still some limitations of this study. First, this study was retrospective, and we did not include patients with other EC operations as a control group. In subsequent research, a well-designed randomized controlled trial should be conducted to comprehensively evaluate the efficacy and safety of this new surgical method. Second, we did not evaluate the long-term quality of life of the patients after surgery. All these limitations should be addressed in future studies.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eWhen the inflation pressures in the mediastinum and abdomen were 10 mmHg and 12 mmHg, respectively, we safely completed surgery without respiratory and circulatory inhibition. In summary, our results show that our single-port inflatable mediastinoscopy with simultaneous laparoscopic radical resection of EC is technically safe and does not increase perioperative complications.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eEC : Esophageal cancer\u003c/p\u003e\n\u003cp\u003eMIE : minimally invasive esophagectomy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTHE : Transhiatal esophagectomy\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSPIMSLE : single-port inflatable mediastinoscopy simultaneous laparoscopic radical esophagectomy\u003c/p\u003e\n\u003cp\u003eCVP : central venous pressure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCO2 : carbon dioxide\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHR :Heart rate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMAP : mean arterial pressure\u003c/p\u003e\n\u003cp\u003epeak AP: peak airway pressure\u003c/p\u003e\n\u003cp\u003eETCO2: end-expiratory CO2 partial pressure\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFiO2: inhaled oxygen concentration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTV : tidal volume\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOI : oxygenation index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVSD : vacuum sealing drainage\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVAS : visual analog scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe hospital ethics committee approval was granted of this article. Consent for publication was obtained from the paitent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Written informed consent was obtained from the patients for publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e All authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study was supported by the Talents start-up funding of Sun Yat-sen University and National Key Research and Development Program of China (2018YFC0910600).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e Haibo Ye and Xiaojin Wang: drafting and revising manuscript. Xiaojian Li: acquisition. Xiangfeng Gan: analysis.Hongcheng Zhong: interpretation of data.\u003c/p\u003e\n\u003cp\u003eQingdong Cao and Xiangwen Wu: design and approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394\u0026ndash;424. PubMed PMID: 30207593. Epub 2018/09/13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLagergren J, Smyth E, Cunningham D, Lagergren P. Oesophageal cancer. The Lancet. 2017;390(10110):2383\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Daele D, Honore P, Collignon J, Polus M, Loly C, Mutijima E, et al. 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Ann Intern Med. 2006 Apr 18;144(8):596\u0026ndash;608. PubMed PMID: 16618957. Epub 2006/04/19. eng.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFujiwara H, Shiozaki A, Konishi H, Otsuji E. Transmediastinal approach for esophageal cancer: A new trend toward radical surgery. Asian J Endosc Surg. 2019 Jan;12(1):30\u0026ndash;6. PubMed PMID: 30681280. Epub 2019/01/27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-David K, Tuttle R, Kukar M, Rossidis G, Hochwald SN. Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population. Ann Surg Oncol. 2016 Sep;23(9):3056\u0026ndash;62. PubMed PMID: 27112585. Epub 2016/04/27. eng.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanekiyo S, Takeda S, Tsutsui M, Nishiyama M, Kitahara M, Shindo Y, et al. Low invasiveness of thoracoscopic esophagectomy in the prone position for esophageal cancer: a propensity score-matched comparison of operative approaches between thoracoscopic and open esophagectomy. Surg Endosc. 2018 Apr;32(4):1945\u0026ndash;53. PubMed PMID: 29075967. Epub 2017/10/28. eng.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin M, Shen Y, Wang H, Fang Y, Qian C, Xu S, et al. A comparison between two lung ventilation with CO2 artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy. J Thorac Dis. 2018 Mar;10(3):1912\u0026ndash;8. PubMed PMID: 29707346. Pubmed Central PMCID: PMC5906341. Epub 2018/05/01.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen NT, Anderson JT, Budd M, Fleming NW, Ho HS, Jahr J, et al. Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass. Surg Endosc. 2004 Jan;18(1):64\u0026ndash;71. PubMed PMID: 14625752. Epub 2003/11/20. eng.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomero KJ, Trujillo MH. Spontaneous pneumomediastinum and subcutaneous emphysema in asthma exacerbation: The Macklin effect. Heart Lung. 2010 Sep-Oct;39(5):444-7. PubMed PMID: 20561891. Epub 2010/06/22. eng.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarczynski M, Herman RM. Influence of different pressures of pneumoperitoneum on the autonomic system function during laparoscopy. Folia Med Cracov. 2002;43(1\u0026ndash;2):51 \u0026ndash; 8. PubMed PMID: 12815798. Epub 2003/06/21. eng..\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNamm JP, Posner MC. Transhiatal Esophagectomy for Esophageal Cancer. J Laparoendosc Adv Surg Tech A. 2016 Oct;26(10):752\u0026ndash;6. PubMed PMID: 27548444. Epub 2016/08/23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeng JS, Kukar M, Mann GN, Hochwald SN. Minimally Invasive Esophageal Cancer Surgery. Surg Oncol Clin N Am. 2019 Apr;28(2):177\u0026ndash;200. PubMed PMID: 30851822. Epub 2019/03/11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiere SSAY, van Berge Henegouwen MI, Maas KW, Bonavina L, Rosman C, Garcia JR, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. The Lancet. 2012;379(9829):1887\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Esophagectomy, inflatable mediastinoscopy, circulation, respiration","lastPublishedDoi":"10.21203/rs.3.rs-642915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-642915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Purpose\u003c/h2\u003e \u003cp\u003eWe previously developed a new surgical method, namely, single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy. The purpose of this study was to evaluate the effect of carbon dioxide inflation on respiration and circulation using this approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom April 2018 to October 2020, 105 patients underwent this novel surgical approach. The changes in respiratory and circulatory functions were reported when the mediastinal pressure and pneumoperitoneum pressure were 10 and 12mmHg, respectively. Data on blood loss, operative time, and postoperative complications were also collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e104 patients completed the operation successfully, except for 1 patient who was converted to thoracotomy because of intraoperative injury. During the operation, respectively, the heart rate, mean arterial pressure, central venous pressure, peak airway pressure, end-expiratory partial pressure of carbon dioxide and partial pressure of carbon dioxide increased in an admissibility range. The pH and oxygenation index decreased 1 hour after inflation, but these values were all within a safe and acceptable range and restored to the baseline level after CO\u003csub\u003e2\u003c/sub\u003e elimination. Postoperative complications included anastomotic fistula (8.6%), pleural effusion that needed to be treated (8.6%), chylothorax (0.9%), pneumonia (7.6%), arrhythmia (3.8%) and postoperative hoarseness (18.2%). There were no cases of perioperative death.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhen the inflation pressure in the mediastinum and abdomen was 10 mmHg and 12 mmHg, respectively, the inflation of carbon dioxide from single-port inflatable mediastinoscopy simultaneous laparoscopic-assisted radical esophagectomy did not cause serious changes in respiratory and circulatory function or increase perioperative complications.\u003c/p\u003e","manuscriptTitle":"Effect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy On Respiration and Circulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-29 19:36:16","doi":"10.21203/rs.3.rs-642915/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-08-12T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-08-07T00:00:00+00:00","index":2,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nJCTS-D-21-00316\nEffect of Single-Port Inflatable Mediastinoscopy Simultaneous Laparoscopic-Assisted Radical Esophagectomy on Respiration and Circulation\n\nThe authors should be congratulated for their well written article about their original surgical technique.\n\nI have some comments.\n\n1) the description of the surgical technique should be improved, a drawing of the surgical access and a video could help the readers to understand the surgical steps.\n\n2) None of the patients received preoperative RT. Is this a routinary choice?\n\n3) I understand that the observation time is short, but an actuarial follow-up could be interesting, if available.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2021-08-05T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept\nForm responses:\n---\n\nComments to Author:\n---\nIt would be useful to plot the increase in insuflationpressure/flow with variation in hemodynamics in one illustration.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Level of interest: **An article whose findings are important to those with closely related research interests**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **'I declare that I have no competing interests'**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2021-07-24T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-07-21T13:30:58+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-07-21T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-07-21T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-06-21T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-06-20T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-06-20T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2021-06-20T10:12:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cca13018-2f41-4fd8-b103-003c8a50c815","owner":[],"postedDate":"June 29th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":5361039,"name":"Cardiac \u0026 Cardiovascular Systems"},{"id":5361040,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2021-09-28T13:25:40+00:00","versionOfRecord":[],"versionCreatedAt":"2021-06-29 19:36:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-642915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-642915","identity":"rs-642915","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}