Ventilation strategies in reconstructive surgery of the tracheal bifurcation and bronchi: a 40-year retrospective institutional experience of 1,345 procedures
Dmitry B Giller, Arina A Arzamasova, Boris D Giller, Alexander E Starozhinsky, Alexander V Ustinov, Igor’ V Smirnov, Inga I Enilenis, Vadim V Koroev, Oleg S Kesaev, Galina V Shcherbakova, Patimat G Gadzhieva, Ludmila P Severova, Alexander D Chuischev, Darya N Kurakina, Ivan I MartelAbstract
Objectives
To evaluate the feasibility, procedural safety, and clinical outcomes of differentiated intraoperative ventilation strategies tailored to the level and complexity of reconstructive surgery on the tracheal bifurcation and bronchi.
Methods
A retrospective descriptive institutional study of 1,345 consecutive reconstructive procedures performed between 1986 and 2025 across four specialized thoracic centers by a single surgical team was conducted. Surgeries were categorized into five procedural groups: circumferential carinal resection (n = 142), partial carinal resection (n = 5), bronchial sleeve resection (n = 231), pneumonectomy with stump-less carinal closure (n = 815), and bronchopleural/tracheopleural fistula repair (n = 152). Intraoperative airway management included selective one-lung volume-controlled ventilation (OLV), catheter-based high-frequency jet ventilation (HFJV), and combined/apnoeic techniques.
Results
No intraoperative deaths occurred, and no complications were directly attributable to ventilation failure. Five transient intraoperative anesthetic incidents occurred in patients with severe cardiopulmonary comorbidities: arterial hypotension (n = 1), supraventricular arrhythmias (n = 2), and asystole/cardiac arrest (n = 2), all successfully resolved. Major postoperative complications occurred in 109 patients (8.1%); 18 patients (1.3%) had complications potentially related to airway management (atelectasis, n = 4; pneumonia, n = 6; acute respiratory distress syndrome, n = 8). Overall 30-day mortality was 0.9% (13/1,345). Mortality was 0% in isolated bronchial resections (0/231), 2.1% after circumferential carinal resection (3/142), 1.3% in post-pneumonectomy fistula repairs (2/152), and 0.98% in stump-less carinal closures (8/815).
Conclusions
A procedure-tailored ventilation strategy provides safe and reliable intraoperative gas exchange. For carinal reconstructions, catheter-based HFJV is technically advantageous by avoiding bulky tubes in the operative field. For isolated bronchial sleeve resections, conventional selective OLV is sufficient. Managing post-pneumonectomy fistulas requires adaptable maneuvers to maintain gas exchange during induction and airway transection.