Recurrent laryngeal nerve paralysis (RLNP) following esophagectomy for carcinoma

Effectiveness of recurrent laryngeal nerve monitoring on nerve paralysis during open McKeown esophagectomy: a prospective, cohort study

BACKGROUND

Recurrent laryngeal nerve paralysis (RLNP) is a critical postoperative complication in esophagectomy. Intraoperative nerve monitoring (IONM) is a technique that can be used in high-risk surgeries to prevent, identify, and mitigate nerve damage. In this prospective study, we evaluated the feasibility and effectiveness of IONM in open McKeown esophagectomy for esophageal cancer.

METHODS

From December 2020 to September 2023, 88 patients diagnosed with esophageal cancer were enrolled to receive IONM for open McKeown esophagectomy at Cancer Center, Sun Yat-sen University. The primary outcome was the incidence of RLNP after extubation. The secondary outcomes were postoperative complications, number of dissected lymph nodes, length of hospital stay, ICU duration and number of deaths.

RESULTS

A total of 83 patients were included in the final analysis. The incidence of RLNP after extubation was 30.1%. The occurrence of postoperative pulmonary complications was 20.5%. The median hospital stays were 13 days. The incidence of anastomotic leakage was 13.3%. No in-hospital deaths were reported. Postoperative RLNP prolonged the length of hospital stay (P = 0.042).

CONCLUSION

Our findings indicated that IONM could potentially be associated with a possible reduction in RLNP incidence following open McKeown esophagectomy for esophageal cancer. However, future research including well-designed randomized controlled trials may be beneficial to clarify these preliminary results.

TRIAL REGISTRATION NUMBER

ChiCTR2000029687 https://www.chictr.org.cn/showproj.html?proj=49103.

Recurrent laryngeal nerve paralysis as a potential mediator of complications in esophagectomy following lymph node dissection

Complications from esophagectomy often interact with each other, with those related to recurrent laryngeal nerve (RLN) paralysis (RLNP) being particularly significant. Aggressive dissection of RLN lymph nodes (RLN-LNs) is considered a major contributing factor to RLNP. This study seeks to validate the hypothesis that RLNP acts as a mediator, not only resulting from RLN-LN dissection but also amplifying the likelihood of other postoperative complications. Data were retrospectively extracted from the Chinese 12th Five-Year Major Science and Technology Project on esophageal diseases, including a cohort of 1684 patients enrolled between 2015 and 2018. Both univariate and multivariate structural equation models were employed to validate the mediating role of RLNP in postoperative complications. Without causing RLNP, RLN-LN dissection directly increased the risk of chylothorax (odds ratio [OR] = 1.179, 95% confidence interval [CI] = 1.003-1.385) and decreased the risk of cardiac arrhythmia (OR = 0.919, 95% CI = 0.838-0.993). Meanwhile, through the mediating effect of RLNP, RLN-LN dissection indirectly led to complications requiring intensive care (OR = 1.043, 95% CI = 1.004-1.083) and conservative therapy (OR = 1.043, 95% CI = 0.996-1.092). RLNP serves as a critical mediator between RLN-LN dissection and subsequent postoperative complications requiring intensive care and conservative therapy. Recognizing that many of these complications are mediated by RLNP could help thoracic surgeons prioritize neural protection during RLN-LN dissection, potentially reducing the overall risk of multiple complications and alleviating the associated concerns.

Multicentre randomized clinical trial on robot-assisted versus video-assisted thoracoscopic oesophagectomy (REVATE trial)

BACKGROUND

Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN.

METHODS

Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes.

RESULTS

From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths.

CONCLUSION

In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).

Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility

Background

The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy.

Methods

This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups.

Results

Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy.

Conclusion

The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

Application of Intraoperative Neuromonitoring (IONM) of the Recurrent Laryngeal Nerve during Esophagectomy: A Systematic Review and Meta-Analysis

BACKGROUND

recurrent laryngeal nerve palsy (RLNP) is a common and severe complication of esophagectomy in esophageal cancer (EC). Several studies explored the application of intraoperative neuromonitoring (IONM) in esophagectomy to prevent RLNP. The purpose of this study was to conduct a systematic review and meta-analysis to evaluate the value of IONM in esophagectomy for EC.

METHODS

an electronic of the literature using Google Scholar, PubMed, Embase, and Web of Science (data up to October 2022) was conducted and screened to compare IONM-assisted and conventional non-IONM-assisted esophagectomy. RLNP, the number of mediastinal lymph nodes (LN) dissected, aspiration, pneumonia, chylothorax, anastomotic leakage, the number of total LN dissected, postoperative hospital stay and total operation time were evaluated using Review Manager 5.4.1.

RESULT

ten studies were ultimately included, with a total of 949 patients from one randomized controlled trial and nine retrospective case-control studies in the meta-analysis. The present study demonstrated that IONM reduced the incidence of RLNP(Odds Ratio (OR) 0.37, 95% Confidence Interval (CI) 0.26-0.52) and pneumonia (OR 0.58, 95%CI 0.41-0.82) and was associated with more mediastinal LN dissected (Weighted Mean Difference (WMD) 4.75, 95%CI 3.02-6.48) and total mediastinal LN dissected (WMD 5.47, 95%CI 0.39-10.56). In addition, IONM does not increase the incidence of aspiration (OR 0.4, 95%CI 0.07-2.51), chylothorax (OR 0.55, 95%CI 0.17-1.76), and anastomotic leakage (OR 0.78, 95%CI 0.48-1.27) and does not increase the total operative time (WMD -12.33, 95%CI -33.94-9.28) or postoperative hospital stay (WMD -2.07 95%CI -6.61-2.46) after esophagectomy.

CONCLUSION

IONM showed advantages for preventing RLNP and pneumonia and was associated with more mediastinal and total LN dissected in esophagectomy. IONM should be recommended for esophagectomy.

Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer

BACKGROUND

Although single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue.

METHODS

This study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated.

RESULTS

The overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05-0.98) was an independent factor avoiding postoperative RLN palsy.

CONCLUSION

The CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.

Risk factors and long-term postoperative outcomes in patients with postoperative dysphagia after esophagectomy for esophageal cancer

Aim

Dysphagia is one of the most common complications after esophagectomy. However, no study has investigated the long-term postoperative outcomes in patients with postoperative dysphagia. Here, we aimed to identify risk factors for postoperative dysphagia and to investigate long-term postoperative outcomes in such patients.

Methods

This study included 304 consecutive patients with thoracic esophageal cancer who underwent curative esophagectomy. They were diagnosed with postoperative dysphagia through a contrast videofluoroscopic swallowing study, and postoperative outcomes were compared based on swallowing function.

Results

In total, 112 patients (37%) were diagnosed with postoperative dysphagia. Older age, low BMI, and recurrent laryngeal nerve palsy were identified as independent risk factors for postoperative dysphagia. In the dysphagia group, a significantly larger number of patients developed in-hospital pneumonia, and hospital stays were also significantly extended. After discharge, 37 (33%) patients with postoperative dysphagia developed pneumonia. Even more than 1 year after esophagectomy, a significantly larger number of patients (24 patients, 21%) with postoperative dysphagia developed pneumonia compared to those without postoperative dysphagia. Postoperative dysphagia was identified as an independent risk factor for out-of-hospital pneumonia. Regarding nutritional status, there was no difference in weight loss 1 year after esophagectomy, but significant weight loss was observed 2 years after esophagectomy in the dysphagia group.

Conclusion

Postoperative dysphagia was associated with both preoperative patient factors and surgical factors. Moreover, patients with postoperative dysphagia had long-term and short-term pneumonia risk. The personalization of long-term follow-up through more aggressive rehabilitation and nutritional guidance is required for patients with postoperative dysphagia.

Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy

BACKGROUND

Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available.

METHODS

This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM.

RESULTS

The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy.

CONCLUSION

IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

Real-time detection of the recurrent laryngeal nerve in thoracoscopic esophagectomy using artificial intelligence

BACKGROUND

Artificial intelligence (AI) has been largely investigated in the field of surgery, particularly in quality assurance. However, AI-guided navigation during surgery has not yet been put into practice because a sufficient level of performance has not been reached. We aimed to develop deep learning-based AI image processing software to identify the location of the recurrent laryngeal nerve during thoracoscopic esophagectomy and determine whether the incidence of recurrent laryngeal nerve paralysis is reduced using this software.

METHODS

More than 3000 images extracted from 20 thoracoscopic esophagectomy videos and 40 images extracted from 8 thoracoscopic esophagectomy videos were annotated for identification of the recurrent laryngeal nerve. The Dice coefficient was used to assess the detection performance of the model and that of surgeons (specialized esophageal surgeons and certified general gastrointestinal surgeons). The performance was compared using a test set.

RESULTS

The average Dice coefficient of the AI model was 0.58. This was not significantly different from the Dice coefficient of the group of specialized esophageal surgeons (P = 0.26); however, it was significantly higher than that of the group of certified general gastrointestinal surgeons (P = 0.019).

CONCLUSIONS

Our software's performance in identification of the recurrent laryngeal nerve was superior to that of general surgeons and almost reached that of specialized surgeons. Our software provides real-time identification and will be useful for thoracoscopic esophagectomy after further developments.

Clinical significance and outcomes of bilateral and unilateral recurrent laryngeal nerve lymph node dissection in esophageal squamous cell carcinoma: A large-scale retrospective cohort study

Background

The survival benefits of recurrent laryngeal nerve lymph node dissection (RLNLD) in esophageal squamous cell carcinoma (ESCC) are still under debate, and the prognostic value of unilateral RLNLD has been rarely studied. Therefore, the aim of the present study was to investigate the clinical significance and outcomes of RLNLD in ESCC in a large‐scale cohort study, to shed light on the outcomes of unilateral RLNLD, and to identify the factors that affect the prognostic outcome of RLNLD.

Methods

We retrospectively reviewed 1153 patients with thoracic ESCC who underwent right thoracotomy with lymphadenectomy. The impact of RLNLD on disease‐free survival (DFS) and overall survival (OS) was estimated using the Kaplan–Meier method and Cox proportional hazard models. Inverse probability of treatment weighting (IPTW) was performed to adjust for differences in baseline variables in pairwise comparisons. Subgroup analysis of survival and postoperative complications was conducted for selective RLNLD.

Results

RLN lymph node (LN) metastasis was independently associated with tumor location and most other LN station metastases. RLNLD was an independent prognostic factor for DFS and OS. Both patients who underwent unilateral and bilateral RLNLD had significantly better DFS and OS than the non‐RLNLD patients. Furthermore, pairwise comparisons with IPTW confirmed these results, and we found that patients who underwent bilateral RLNLD had better survival than those who underwent unilateral RLNLD. However, subgroup analysis showed that there was no survival benefit and higher morbidity after bilateral RLNLD for patients with cancer in the lower thoracic esophagus, and elderly and female patients.

Conclusion

RLN LN metastasis is very frequent in ESCC, and both unilateral and bilateral RLNLD have considerable survival benefits. Selective RLNLD with better survival and lower morbidity was recommend for some defined subgroups.

Efficacy of Intraoperative Recurrent Laryngeal Nerve Monitoring During Thoracoscopic Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis

Background: Recurrent laryngeal nerve paralysis (RLNP), a severe complication of mini-invasive esophagectomy, usually occurs during lymphadenectomy adjacent to recurrent laryngeal nerve. This systematic review and meta-analysis aimed to evaluate the efficacy of intraoperative nerve monitoring (IONM) in reducing RLNP incidence during mini-invasive esophagectomy. Methods: Systematic literature search of PubMed, EMBASE, EBSCO, Web of Knowledge, and Cochrane Library until June 4, 2021 was performed using the terms "(nerve monitoring) OR neuromonitoring OR neural monitoring OR recurrent laryngeal nerve AND (esophagectomy OR esophageal)." Primary outcome was postoperative RLNP incidence. Secondary outcomes were sensitivity, specificity, and positive and negative predictive values for IONM; complications after esophagectomy; number of dissected lymph nodes; operation time; and length of hospital stay. Results: Among 2,330 studies, five studies comprising 509 patients were eligible for final analysis. The RLNP incidence was significantly lower (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.12-0.88, p < 0.05), the number of dissected mediastinal lymph nodes was significantly higher (mean difference 4.30, 95%CI 2.75-5.85, p < 0.001), and the rate of hoarseness was significantly lower (OR 0.14, 95%CI 0.03-0.63, p = 0.01) in the IONM group than in the non-IONM group. The rates of aspiration (OR 0.31, 95%CI 0.06-1.64, p = 0.17), pneumonia (OR 1.08, 95%CI 0.70-1.67, p = 0.71), and operation time (mean difference 7.68, 95%CI -23.60-38.95, p = 0.63) were not significantly different between the two groups. The mean sensitivity, specificity, and positive and negative predictive values for IONM were 53.2% (0-66.7%), 93.7% (54.8-100%), 71.4% (0-100%), and 87.1% (68.0-96.6%), respectively. Conclusion: IONM was a feasible and effective approach to minimize RLNP, improve lymphadenectomy, and reduce hoarseness after thoracoscopic esophagectomy for esophageal cancer, although IONM did not provide significant benefit in reducing aspiration, pneumonia, operation time, and length of hospital stay.

Postoperative complications and perioperative management of lung resection in patients with a history of oesophagectomy for oesophageal carcinoma

 

OBJECTIVES

Advances in chemoradiation have improved the long-term prognosis of oesophageal cancer, although perioperative management for lung resection postoesophagectomy is unknown. The purpose of this study was to investigate postoperative complications and perioperative management for lung resection postoesophagectomy.

METHODS

Between 2002 and 2017, a total of 4694 patients underwent lung resections; of these, 79 were performed postoesophagectomy. Using propensity score matching, we analysed postoperative complications between groups with and without postoesophagectomy lung resection. We also investigated the risk factors of Clavien-Dindo classification grade ≥2 complications by logistic regression analysis.

RESULTS

Sixty-nine of the patients were men with a median age of 67 years. The types of lung resections were as follows: lobectomy in 34, segmentectomy in 12 and wedge resection in 33 patients. Postoperative complications were detected in 35 patients, including grade ≥2 complications in 24. After matching, aspiration pneumonia (P = 0.09) tended to be common in the postoesophagectomy group. Until 2008, non-fasting management before lung resection was performed in all 31, and intraoperative aspiration pneumonia was detected in 2 patients. After switching to fasting management before lung resection, there were no cases of intraoperative aspiration pneumonia. Multivariable analysis revealed that lung resection ipsilateral to oesophagectomy (P = 0.04) and lobectomy (P = 0.03) were predictors of grade ≥2 morbidity.

CONCLUSIONS

Patients having a lung resection postoesophagectomy tended to have a higher risk of aspiration pneumonia. Fasting management before lung resection is important in preventing intraoperative aspiration pneumonia. Lung resection ipsilateral to oesophagectomy and lobectomy may result in complications requiring therapeutic intervention.

Robot-Assisted Versus Conventional Minimally Invasive Esophagectomy for Resectable Esophageal Squamous Cell Carcinoma: Early Results of a Multicenter Randomized Controlled Trial: the RAMIE Trial

OBJECTIVE

To compare perioperative and long-term outcomes of robot-assisted minimally invasive esophagectomy (RAMIE) and conventional minimally invasive esophagectomy (MIE) in the treatment for patients with esophageal squamous cell carcinoma (ESCC).

SUMMARY BACKGROUND DATA

RAMIE has emerged as an alternative to traditional open or thoracoscopic approaches. Efficacy and safety of RAMIE and MIE in the surgical treatment for ESCC remains uncertain given the lack of high-level clinical evidence.

METHODS

The RAMIE trial was designed as a prospective, multicenter, randomized, controlled clinical trial that compare the efficacy and safety of RAMIE and MIE in the treatment of resectable ESCC. From August 2017 to December 2019, eligible patients were randomly assigned to receive either RAMIE or MIE performed by experienced thoracic surgeons from six high-volume centers in China. Intent-to-treat analysis was performed.

RESULTS

Significantly shorter operation time was taken in RAMIE (203.8 vs. 244.9 mins, P<0.001). Compared to MIE, RAMIE showed improved efficiency of thoracic lymph node dissection in patients who received neoadjuvant therapy (15 vs. 12, P=0.016), as well as higher achievement rate of lymph node dissection along the left recurrent laryngeal nerve (RLN) (79.5% vs. 67.6%, P=0.001). No difference was found in blood loss, conversion rate, and R0 resection. The 90-day mortality was 0.6% in each group. Overall complications were similar in RAMIE (48.6%) compared to MIE (41.8%) (RR, 1.16; 95% CI, 0.92-1.46; P=0.196). Besides, the rate of major complications (Clavien-Dindo classification ≥ III) was also comparable (12.2% vs. 10.2%, P=0.551). RAMIE showed similar incidences of pulmonary complications (13.8% vs. 14.7%; P=0.812), anastomotic leakage (12.2% vs. 11.3%; P=0.801) and vocal cord paralysis (32.6% vs. 27.1%, P=0.258) to MIE.

CONCLUSIONS

Early results demonstrate that both RAMIE and MIE are safe and feasible for the treatment of ESCC. RAMIE can achieve shorter operative duration as well as better lymph node dissection in patients who received neoadjuvant therapy. Long-term results are pending for further follow-up investigations.

TRIAL REGISTRATION

ClinicalTrial.gov Identifier: NCT03094351.

Management of Postoperative Complications After Esophageal Resection

Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.

Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis

Background

There are no effective preoperative diagnostic measures to predict the probability of left and right recurrent laryngeal nerve (RLN) lymph node (LN) metastasis using preoperative clinical data in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis.

Methods

We retrospectively reviewed the clinical data of 1,660 consecutive patients with thoracic esophageal cancer who underwent esophagectomy with cervical anastomosis at the Department of Thoracic Surgery at the First Affiliated Hospital of Zhengzhou University between January 2015 and December 2020.

Results

A total of 299 and 343 patients who underwent left (Cohort 1) and right (Cohort 2) RLN LN dissection were included in the final analyses. The analyses were conducted within each cohort. Among the 299 patients in Cohort 1, left RLN LN involvement was found in 41 patients (13.7%). A multivariable analysis showed that age, tumor location, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Among the 343 patients in Cohort 2, right RLN LN involvement was found in 65 patients (19.0%). A multivariable analysis showed that computed tomography (CT) appearance, tumor location, long axis, and short axis were significantly associated with RLN LN metastasis (all P<0.05). Based on the results of the multivariable analyses, we constructed nomograms that could estimate the probability of RLN LN metastasis. Finally, we stratified the 2 cohorts into risk subgroups using a recursive partitioning analysis (RPA). The risk of left and right RLN LN metastasis was found to be 9.3% and 7.5%, 27.3% and 21.4%, and 52.4% and 47.3% for the low-risk, intermediate-risk, and high-risk groups, respectively.

Conclusions

Our nomograms and RPAs appear to be suitable for the risk stratification of left and right RLN LN metastasis in patients undergoing thoracolaparoscopic esophagectomy with cervical anastomosis. This tool could be used to help clinicians to select more effective locoregional treatments, such as surgical protocols and radiation area selection.

Management of patients with bilateral recurrent laryngeal nerve paralysis following esophagectomy

Background

Recurrent laryngeal nerve paralysis (RLNP) is a common complication after esophagectomy which can cause severe pulmonary complications. However, bilateral RLNP has been rarely reported in esophagectomy patients. The objective of our study is to investigate the clinical significance of patients who had bilateral RLNP following esophagectomy.

Methods

We retrospectively reviewed patients who underwent esophagectomy at a single center from 1994 to 2018. Among these, patients with bilateral vocal cord paralysis were included in this study.

Results

A total of 3217 patients were reviewed and 400 (12.4%) patients had RLNP, including 56 patients with bilateral RLNP identified by laryngoscopic examination. During the postoperative managements, 10 of the 56 patients (17.9%) required tracheostomy. Among them, two died of acute respiratory distress syndrome and the other eight patients were discharged after removing the tracheostomy tube. The median lengths of hospital and intensive care unit stay were 19.5 (range 8–157) and 2 (range 1–46) days, respectively. Forty‐six patients (83.6%) were discharged with oral feeding after swallowing therapy including tongue holding maneuver and head tilt exercise. The other five patients (8.9%) were discharged with alternative enteral feeding via jejunostomy, but they were able to achieve oral diet 2–3 months after surgery.

Conclusion

Bilateral RLNP following esophagectomy was rare, but it required great attention to prevent severe respiratory complications. However, only a few patients required tracheostomy and the majority achieved oral ingestion after intensive rehabilitation. Feeding education and respiratory rehabilitation are critical during the management of patients with bilateral RLNP.

Preoperative computed tomography predicts the risk of recurrent laryngeal nerve paralysis in patients with esophageal cancer undergoing thoracoscopic esophagectomy in the prone position

BACKGROUND

Recurrent laryngeal nerve paralysis (RLNP) after thoracoscopic esophagectomy for esophageal cancer (EC) is known to be a major complication leading to poor quality of life. RLNP is mainly associated with surgical procedures performed near the RLN. Therefore, with focus on the region of the RLN, we used preoperative computed tomography to investigate the risk factors of RLNP in patients with EC undergoing thoracoscopic esophagectomy.

METHODS

We retrospectively examined 77 EC patients who underwent thoracoscopic esophagectomy in the prone position at our department between January 2010 and December 2018. Bilateral cross-sectional areas (mm²) of the fatty tissue around the RLN at the level of the lower pole of the thyroid gland were measured on preoperative axial computed tomography (CT) images. Univariate and multivariate logistic regression analysis was used to evaluate the association between the incidence of RLNP and patient clinical factors, including the cross-sectional areas.

RESULTS

RLNP occurred in 24 of 77 patients (31.2%). The incidence of RLNP was significantly more frequent on the left side than on the right. (26% vs. 5.2%, respectively). Univariate analysis identified the following left RLNP risk factors: intrathoracic operative time (> 235 min), and area around the RLN (> 174.3 mm²). Multivariate analysis found that the area around the RLN was an independent risk factor of left RLNP.

CONCLUSION

An increased area around the RLN measured on an axial CT view at the level of the lower pole of the thyroid gland was a risk factor of RLNP in EC patients undergoing thoracoscopic esophagectomy in the prone position.

The Impact of the Recurrent Laryngeal Nerve Injury on Prognosis After McKeown Esophagectomy for ESCC

Background

The objective of this study was to assess the impact of the recurrent laryngeal nerve injury (RLNI) after esophagectomy on prognosis.

Methods

Retrospectively collected data from 297 patients with esophageal squamous cell carcinoma (ESCC) who underwent McKeown esophagectomy at our department from April 2014 to May 2018, were analyzed.

Results

RLNI occurred in 31.9% of the patients. Left-side RLNI occurred 2.8 times more often than right-side RLNI. Among the cases in which assessment of the vocal cords was continued, 8.4% involved permanent injury. There were no significant differences among clinicopathological data between patients with RLNI and without. Compared with patients without RLNI, patients with RNLI have longer operation time, more number of bronchoscopy suctions, longer postoperation hospital stay, and higher incidence of postoperative complications. T stage, N stage, RLN lymph node metastasis were independent risk factors for the prognosis, but RLNI is not independent risk factors for long-term survival.

Conclusion

RLNI is a serious complication that will affect the short-term prognosis of patients and reduce the quality of life of patients. It should be avoided as much as possible during surgery, but it may not have negative impact on the long-term survival.

Intraoperative neuromonitoring during prone thoracoscopic esophagectomy for esophageal cancer reduces the incidence of recurrent laryngeal nerve palsy: a single-center study

The incidence of recurrent laryngeal nerve palsy (RLNP) following minimally invasive esophagectomy has yet to be satisfactorily reduced. Use of intraoperative neuromonitoring (IONM), specifically of the RLN, during thyroidectomy has been reported to reduce the incidence of RLN injury. We now apply IONM during curative prone thoracoscopic esophagectomy, and we conducted a retrospective study to evaluate the feasibility and efficacy of intermittent monitoring of the RLN during the surgery. The study involved 32 consecutive patients who underwent esophagectomy with radical lymph node dissection for esophageal cancer. The patients were of two groups: an IONM group (n = 17) and a non-IONM group (n = 15). We chiefly strip around the esophagus preserving the membranous structure, which contains the tracheoesophageal artery, lymph nodes, and RLN. In the IONM group patients, we stimulated the RLN and measured the electromyography (EMG) amplitude after dissection, at the dissection starting point and dissection end point on both sides. For the purpose of the study, we compared outcomes between the two groups of patients. IONM was carried out successfully in all 17 patients in the IONM group. The incidence of RLNP was significantly reduced in this group. We found that both RLNs can be identified by mean of IONM easily, immediately, and safely and that the EMG amplitude attenuation rate is particularly useful for predicting RLNP.

Combined Intraoperative Identification and Monitoring of Recurrent Laryngeal Nerve Paresis during Minimally Invasive Esophagectomy: Surgical Technique Using Nerve Integrity Monitoring for Esophageal Carcinoma

Recurrent laryngeal palsy occurs after No. 106 rec RL lymphadenectomy procedure, which is assumed to cause postoperative respiratory complications. A 71-year-old Japanese man with T1b N0 M0 stage 1 esophageal cancer was scheduled for thoracoscopic esophagectomy with two-field lymph node dissection using nerve integrity monitoring (NIM). The patient demonstrated an uneventful postoperative course with 56 days remission. Under general anesthesia conditions, a single-lumen intubation tube was inserted for NIM. The automatic periodic stimulation electrode was placed on the bilateral vagus nerves on the left and right, respectively. The NIM had set and enabled the identification of the nerve accurately and continuous intraoperative nerve monitoring using impulses from the stimulation probe. The postoperative outcomes and comparison of the potential amplitudes of electromyography were observed while no postoperative vocal cord paresis was present. Combined intraoperative identification and monitoring of recurrent laryngeal nerve significantly changes the quality of the lymphadenectomy procedure and is a promising optical imaging technique. It has gained recognition for being able to reduce or prevent recurrent laryngeal nerve paralysis. It was considered a reasonable method, but it has been superseded by NIM, which is a novel technology.

Endobronchial Ultrasound Improves Evaluation of Recurrent Laryngeal Nerve Lymph Nodes in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

The bilateral recurrent laryngeal nerve (RLN) lymph nodes are the most common metastatic site for esophageal squamous cell carcinoma (ESCC); however, the RLNs are susceptible to injury during dissection. Clinically, there is an urgent need to determine an effective diagnostic method for RLN nodes to help achieve selective nodal dissection and avoid potential serious complications by performing more conservative surgery for those with nonmetastatic nodes. Here, we innovatively applied endobronchial ultrasonography (EBUS) and investigated its diagnostic performance for preoperative evaluation of RLN nodes in ESCC patients.

PATIENTS AND METHODS

All 81 enrolled ESCC patients underwent preoperative EBUS and CT examinations. The ability of EBUS and CT to detect RLN node metastasis was evaluated based on the resulting sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The diagnostic performance of EBUS was superior to that of CT; in particular, EBUS of the left RLN (L-RLN) nodes presented the best sensitivity, specificity, PPV, NPV, and accuracy compared with EBUS evaluations of the right RLN (R-RLN) nodes, CT of the L-RLN and R-RLN nodes. Moreover, EBUS combined with CT increased the NPV relative to that of EBUS or CT alone, promoting the ability to identify true-negative RLN nodes. In particular, the NPVs of the combined modality were 100% for both the L- and R-RLN nodes in early-T-stage (T1-T2) ESCC.

CONCLUSIONS

EBUS is an efficient tool for RLN node evaluation, and the combination with CT may provide better guidance for selective RLN node dissection in ESCC patients.

Major Postoperative Complications in Esophageal Cancer After Minimally Invasive Esophagectomy Compared With Open Esophagectomy: An Updated Meta-analysis

BACKGROUND

To evaluate the existing literature comparing cardiopulmonary complications after minimally invasive esophagectomy (MIE) with open esophagectomy (OE) and conduct a meta-analysis based on the relevant studies.

METHODS

A systematic search for articles was performed in Medline, Embase, Wiley Online Library, and the Cochrane Library. The relative risks or odds ratios (ORs) were calculated by using fixed or random-effects models. The I² and X² tests were used to test for statistical heterogeneity. We performed a metaregression for the pulmonary complications with the adenocarcinoma proportion and tumor stage. Publication bias and small-study effects were assessed using Egger's test and Begg's funnel plot.

RESULTS

A total of 30,850 participants were enrolled in the 63 studies evaluated in the meta-analysis. Arrhythmia, pulmonary embolism, pulmonary complications, gastric tip necrosis, anastomotic leakage, and vocal cord palsy were chosen as outcomes. The occurrence rate of arrhythmia was significantly lower in patients receiving MIE than in patients receiving OE (OR = 0.69; 95% CI = 0.53-0.89), with heterogeneity (I² = 30.7%, P = 0.067). The incidence of pulmonary complications was significantly lower in patients receiving MIE (OR = 0.54, 95% CI = 0.45-0.63) but heterogeneity remained (I² = 72.1%, P = 0.000). The risk of gastric tip necrosis (OR = 1.48, 95% CI = 1.07-2.05) after OE was lower than that after MIE. Anastomotic leakage, pulmonary embolism, and vocal cord palsy showed no significant differences between the two groups.

CONCLUSIONS

MIE has advantages over OE, especially in reducing the incidence of arrhythmia and pulmonary complications. Thus, MIE can be recommended as the preferred alternative surgery method for resectable esophageal cancer.

Two trajectories of functional recovery in thyroid surgery related unilateral vocal cord paralysis

BACKGROUND

Iatrogenic unilateral vocal fold paralysis caused by thyroid surgery induces profound physical and psychosocial distress in patients. The natural course of functional recovery over time differs substantially across subjects, but the mechanisms underlying this difference remain unclear. In this study, we examined whether the anatomic site of the lesion affected the trajectory of recovery.

METHODS

In this prospective case series study in a single medical center, patients with thyroid surgery-related unilateral vocal fold paralysis were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 quality-of-life questionnaire. Patients with and without superior laryngeal nerve injuries were compared.

RESULTS

Forty-two patients were recruited, among whom 15 and 27 were assigned to the with and without superior laryngeal nerve injury groups, respectively. Compared with the group without superior laryngeal nerve injury, the group with superior laryngeal nerve injury group demonstrated less improvement in the recruitment of vocal fold adductors, and the group also had more severe impairment of vocal fold vibration, maximum phonation time, jitter, shimmer, and harmony-to-noise ratio at the first evaluation. This difference was also found in the glottal gap and maximum phonation time 12 months after the injury.

CONCLUSION

Among patients with thyroid surgery-related unilateral vocal fold paralysis, superior laryngeal nerve injury induces a distinctively different recovery trajectory compared with those without superior laryngeal nerve injury characterized by less reinnervation of vocal fold adductors and worse presentation in terms of the glottal gap and maximum phonation time. This study emphasizes the importance of superior laryngeal nerve function and its preservation in thyroid surgery.

Anomalies of the right vertebral vein increasing the difficulty of lymph-node dissection along the right recurrent laryngeal nerve: a single-institution, retrospective study

BACKGROUND

Radical lymph-node dissection along the recurrent laryngeal nerves (RLN) improves the prognosis of patients with esophageal cancer. The RLN is a landmark for achieving adequate lymph-node dissection. However, the right RLN is sometimes covered by the right vertebral veins (VVs), making it undetectable. We investigated the relationship between this anomaly of the right VVs and the challenges of performing lymphadenectomy along the right RLN.

METHODS

Patients with esophageal cancer, who underwent thoracoscopic esophagectomy with radical lymph-node dissection, were registered. The patterns of the right VVs were evaluated by preoperative computed tomography. The time required for identifying the right RLN or completing the lymphadenectomy was determined by reviewing surgical videos.

RESULTS

In total, 178 patients were enrolled. Eighty patients (45%) had right VVs passing dorsal to the right subclavian artery (Dorsal group). More time was required to detect the right RLN in these cases (11 vs 9.5 min for the other cases, p = 0.034). In the Dorsal group, there were 15 patients who had specific VV patterns: The right VV converged on the lower portion of the right brachiocephalic vein (BCV), or passed through to the more medial side of the mediastinum. These patients required more time for detecting the right RLN (25 vs 9 min, p < 0.0001) and for completing the lymphadenectomy (41 vs 32 min, p = 0.048) than the other cases.

CONCLUSION

The right VVs behind the subclavian artery, joining the lower part of the BCV or passing through the medial side, made it difficult to identify the right RLN and complete the lymphadenectomy.

Learning curve associated with thoraco-laparoscopic esophagectomy for esophageal cancer patients in the prone position

Objective

To observe the surgical index at the different learning stages of thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer and to investigate the learning curve of this surgical procedure.

Methods

Sixty thoraco-laparoscopic esophagectomies in the prone position for esophageal cancer conducted by the same group of surgeons between January 2014 and December 2015 were retrospectively analyzed. The surgeries were divided into 5 groups, A, B, C, D, and E, in chronological order. The duration of surgery, intraoperative blood loss, total number of lymph nodes removed, rate of the intraoperative conversion to open surgery, complication rate, and length of postoperative hospitalization were recorded and analyzed.

Results

The general information of the patients did not significantly differ among the 5 groups (P > 0.05). The duration of surgery, intraoperative blood loss, number of lymph node removed, rate of intraoperative conversion to open surgery, and number of injuries to the recurrent laryngeal nerve all significantly differed (P < 0.05). The rates of postoperative pulmonary infection, anastomotic fistula, pneumothorax, and hospitalization did not significantly differ (P > 0.05).

Conclusion

Thoracic physicians with some endoscopic experience can meet the requirements of the thoraco-laparoscopic esophagectomy in the prone position for esophageal cancer after completing 24–30 surgeries.

Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy

BACKGROUND

In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications.

AIM

To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position.

METHODS

The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named “bilateral exposure method”). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018.

RESULTS

There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312).

CONCLUSION

This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery

Background

Esophageal cancer patients can benefit from dissection of the recurrent laryngeal nerve (RLN) lymph node (LN); however, this procedure increases the risk of RLN injury. After nerve injury, many complications can occur, including choking cough, which can affect patients' quality of life. This study examined the effectiveness of the chin-down-plus-larynx-tightening maneuver for improving choking cough after radical thoracic esophageal cancer surgery.

Methods

Sixty-two patients with resectable thoracic esophageal cancer presented with choking cough, hoarseness or vocal cord paralysis after radical operations. Twenty-two patients who choked on water were guided to swallow 1 mL of warm water using a chin-down-plus-larynx-tightening maneuver. Choking cough relief results and their relationships with clinical factors were analyzed.

Results

No correlation was found between the occurrence of post-operative choking cough and gender, age, surgical method, hoarseness, vocal cord fixation type, vocal cord fixation, or glottal closure. Multivariate regression analysis revealed no independent risk factors associated with choking cough. Choking cough was completely relieved in 17 of 22 (77.3%) patients. Fifteen of 19 (78.9%) patients with choking cough and hoarseness, and 2 of 3 patients with only choking cough reported complete relief when they tried the new maneuver. The chin-down-plus-larynx-tightening maneuver was more effective for males than for females.

Conclusions

The chin-down-plus-larynx-tightening maneuver significantly relieved choking cough; thus, this maneuver can aid in managing choking cough after radical thoracic esophageal cancer surgery.

A nomogram prediction model for recurrent laryngeal nerve lymph node metastasis in thoracic oesophageal squamous cell carcinoma

Background

The metastasis rate to the recurrent laryngeal nerve lymph node (RLN LN) is high, but resection of it is challenging and increases complications. This study explored the risk factors for the RLN LN metastasis in thoracic oesophageal squamous cell carcinoma and developed a novel scoring system to predict it.

Methods

We retrospectively analysed the clinicopathological data of 265 patients between 2015 and 2018. Univariate and multivariate analyses were performed to screen for risk factors and establish a logistic regression model to predict the risk of RLN LN metastasis. A nomogram was constructed accordingly. Further analyses were conducted regarding right and left RLN LN metastasis alone.

Results

(I) The metastatic rates of the left and right RLN LN were 15.1% and 20.4%, respectively. (II) Multivariate logistic regression analysis showed that the short axis diameter of the left RLN LN, short axis diameter of the right RLN LN, maximum diameter of the tumor, tumor location, subcarinal lymph node status and paraoesophageal lymph node status were all independent risk factors for RLN LN metastasis. (III) Multivariate logistic regression analysis showed that the short axis diameter of right RLN LN, tumor location and subcarinal lymph node status were independent risk factors for right RLN LN metastasis. (IV) Multivariate logistic regression analysis showed that short axis diameter of left RLN LN was an independent risk factor for left RLN LN metastasis.

Conclusions

The metastatic rates of the left and right RLN LNs were high and can be predicted according to these nomograms.

Combined recurrent laryngeal nerve monitoring and one-lung ventilation using the EZ-Blocker and an electromyographic endotracheal tube

Background

Intraoperative neuromuscular monitoring (IONM) is a widespread procedure to identify and protect the recurrent laryngeal nerve (RLN) during thyroid surgery. However, for left thoracic surgery with high risk of RLN injury, both reliable recurrent laryngeal nerve monitoring and one-lung ventilation could interfere.

Methods

In this prospective study, a new method for IONM during one-lung ventilation combining RLN monitoring with an electromyographic (EMG) endotracheal tube (ETT) and lung separation using the EZ-Blocker (EZB) is described and its clinical feasibility and effectiveness were assessed.

Results

A total of 14 patients undergoing left upper lobe surgery and left upper mediastinal lymph node dissection were enrolled. The EZB was introduced and positioned without any problems and sufficient lung collapse was achieved in all patients. No tracheobronchial injuries or immediate complications occurred. A stable EMG signal was present in all patients and no RLN palsy and no negative side effects of the NIM EMG ETT or the EZB were observed postoperatively.

Conclusions

The described method is technically feasible, easy to apply and save. It provides both reliable IONM and independent lung separation for optimal surgical exposure. The combined use of the EZB and the NIM EMG ETT might reduce the risk for RLN palsy and impaired lung separation during left thoracic surgery with high risk for RLN injury.

Lymph node dissection along the recurrent laryngeal nerves in patients with oesophageal cancer who had undergone chemoradiotherapy: is it safe?

OBJECTIVES

Upper mediastinal lymph node dissection (LND)-especially along the recurrent laryngeal nerve (RN)-is the most challenging part of oesophageal cancer surgery. We investigated whether thoracoscopic RN LND may be safely performed in patients with oesophageal cancer who had undergone chemoradiotherapy (CRT).

METHODS

Patients with oesophageal cancer who had undergone thoracoscopic RN LND (n = 103) were divided into 2 groups according to whether they had prior treatment with CRT or not [the CRT group (n = 65) vs the upfront surgery group (n = 38), respectively]. All patients were operated on by a single surgeon. Intergroup comparisons were made in terms of (i) the number of dissected nodes, (ii) rates of RN palsy and (iii) rates of perioperative complications. The learning curve for the RN LND procedure was investigated using the cumulative sum method.

RESULTS

RN LND after CRT was more technically challenging when performed in the left side. Complete skeletonization of the left RN was achieved only in 66.2% of patients in the CRT group (vs 86.8% in the upfront surgery group; P = 0.022). The rate of postoperative left side RN palsy was significantly higher in the CRT group (26.6%) than in the upfront surgery group (7.9%, P = 0.022), albeit resulting in neither higher pneumonia rates nor longer hospital stays. The cumulative sum analysis revealed a steep learning curve for left RN LND in the CRT group. Unfortunately, an acceptable proficiency (left RN palsy rate: 15%) was not achievable even after treatment in 65 cases.

CONCLUSIONS

Thoracoscopic RN LND is safe but poses significant challenges in CRT-treated patients.

Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE): study protocol for a randomized controlled trial

BACKGROUND

Radical lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is surgically demanding and can be associated with substantial postoperative morbidity. The question of whether robot-assisted esophagectomy (RE) might be superior to video-assisted thoracoscopic esophagectomy (VATE) for performing LND along the RLN in patients with esophageal squamous cell carcinoma (ESCC) remains open.

METHODS/DESIGN

We will conduct a multicenter, open-label, randomized controlled trial (Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE)) enrolling patients with ESCC scheduled to undergo LND along the RLN. Patients will be randomly assigned to either RE or VATE. The primary outcome measure will be the rate of unsuccessful LND along the left RLN, which will be defined as: failure to remove lymph nodes along the left RLN (i.e., no identifiable nodes on pathology reports); or occurrence of permanent (duration > 6 months) left RLN palsy following LND. Secondary outcomes will include the number of successfully removed RLN nodes, postoperative recovery, length of hospital stay, 30-day and 90-day mortality, quality of life, and oncological outcomes.

DISCUSSION

The REVATE study provides an opportunity to explore whether RE could facilitate LND along the left RLN-a complex surgical procedure that, as of now and with the use of VATE, remains difficult to perform and associated with a significant burden of morbidity.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03713749 . Registered on 22 October 2018.

Reducing pulmonary complications after esophagectomy for cancer

The cornerstone of curative care for esophageal cancer is neoadjuvant chemoradiotherapy followed by esophagectomy with a radical lymphadenectomy. An esophagectomy is a major and complex surgical procedure and is often followed by postoperative morbidity, especially pulmonary complications. These complications may lead to an increase in hospital stay, intensive care unit admission rate and mortality. Therefore, perioperative strategies to reduce these complications have been investigated and implemented in clinical practice. In this review we highlight the influence of minimally invasive surgery, postoperative pain management, early identification of complications and the usage of uniform definitions on (pulmonary) complications after esophagectomy. Finally, we will discuss some future perspectives.

Usefulness of intraoperative nerve monitoring in esophageal cancer surgery in predicting recurrent laryngeal nerve palsy and its severity

BACKGROUND

Recurrent laryngeal nerve (RLN) palsy is a critical postoperative complication in esophageal cancer surgery. However, intraoperative prediction of its occurrence and severity is difficult. In this prospective study, we evaluated the usefulness of intraoperative nerve monitoring (IONM) in predicting RLN palsy and its severity.

METHODS

Twenty patients who underwent subtotal esophagectomy with 3-field lymph node dissection were enrolled. Intraoperative electromyography (EMG) amplitudes of the vocal cords were measured by IONM at RLN and vagus nerve (VN) stimulation. Comparison was made between the vocal cords with RLN palsy and those without palsy and additionally between the vocal cords with transient RLN palsy and those with persistent palsy.

RESULTS

Among 40 vocal cords in 20 patients, 26 were intact and 14 were paralyzed. Seven had transient, six had permanent palsy. The mean EMG amplitude of intact vocal cords was significantly larger than that of paralyzed ones at VN (506 ± 498 µV vs. 258 ± 226 µV, p = 0.022) and RLN stimulation (642 ± 530 µV vs. 400 ± 308 µV, p = 0.038). The cut-off value for postoperative palsy were 419 µV [positive predictive value (PPV): 48.0%, negative predictive value (NPV): 84.6%] at VN and 673 µV (PPV: 44.8%, NPV: 90.9%) at RLN stimulation. The mean EMG amplitude of persistently paralyzed vocal cords tended to be small, compared with that of recovered ones at both VN (168 ± 173 µV vs. 336 ± 266 µV, p = 0.11) and RLN (244 ± 223 µV vs. 536 ± 344 µV, p = 0.051) stimulation.

CONCLUSION

The absolute EMG amplitude of IONM might be helpful to predict the occurrence and severity of RLN palsy after esophageal surgery although the predictive value is low.

Lateral thermal spread induced by energy devices: a porcine model to evaluate the influence on the recurrent laryngeal nerve

BACKGROUND

Recurrent laryngeal nerve (RLN) paralysis is a frequently observed complication after esophagectomy, and thermal injury is considered to be one of the causes. The difference in the lateral thermal spread associated with the grasping range of various energy devices remains unknown.

METHODS

Ultrasonic devices (Harmonic® HD1000i and Sonicision™) and a vessel-sealing device (Ligasure™) were studied. We evaluated the temperature of these devices, the activation time required, and the thermal spread on porcine muscle when the devices were used with different grasping ranges (thermal spread study). In addition, we evaluated the influence of thermal spread by short grasping use of the energy devices on the viability of RLN in a live porcine model (NIM study).

RESULTS

In the thermal spread study, the temperature of the ultrasonic devices lowered as grasping range increased, whereas the highest temperature of Ligasure was observed when used with two-thirds grasping. The activation time of ultrasonic devices became longer as grasping range increased, whereas the grasping range did not influence the activation time of Ligasure. Thermal spreads 1 mm from the energy devices were unaffected by the grasping ranges. Although the temperature of the Ligasure was lower than that of the ultrasonic devices, thermal spread by Ligasure was significantly greater than that induced by the ultrasonic devices. In the NIM study, the activation of the Sonicision with one-third grasping range did not cause EMG changes at distances of up to 1 mm from the RLN, whereas applying Ligasure with a one-third grasping range 1 mm away from the RLN led to a critical result.

CONCLUSIONS

The grasping range did not influence the thermal spread induced by the energy devices. Ultrasonic devices may be safer in terms of lateral thermal spread to the RLN than Ligasure.

Robot-assisted mediastinoscopic esophagectomy for esophageal cancer: the first clinical series

BACKGROUND

Radical esophagectomy for esophageal cancer is associated with high morbidity, especially with pulmonary complications. Mediastinoscopic esophagectomy via a small left neck incision combined with the esophageal hiatus, without using transthoracic approach, has been reported to reduce pulmonary complication; however, from technical point of view, this approach using non-articulating, straight, long forceps is extremely challenging, especially in the middle mediastinal area. Its technical difficulties may be attenuated using da Vinci Surgical System. The aim of this study was to evaluate the feasibility and safety of robot-assisted mediastinoscopic esophagectomy.

METHODS

Robot-assisted mediastinoscopic esophagectomy was performed in six patients between October 2016 and May 2017. Robotic esophageal mobilization with upper and middle mediastinal lymphadenectomy was performed via the three da Vinci Xi (Intuitive Surgical, Inc. Sunnyvale, CA) trocars placed on the 5-cm left cervical incision. Thereafter, the remaining part of radical esophagectomy was completed via a transhiatal approach.

RESULTS

Upper and middle mediastinal lymphadenectomy was robotically completed via the transcervical approach in all cases without conversion to transthoracic approach. No postoperative complications (Clavien-Dindo classification grade ≥ III) were observed.

CONCLUSIONS

Robot-assisted mediastinoscopic esophagectomy was technically feasible and safe. Use of da Vinci Surgical System may help attenuate technical difficulties in transcervical middle mediastinal lymph node dissection.

Prevalence and resource utilization for vocal fold paralysis/paresis after esophagectomy

OBJECTIVES/HYPOTHESIS

Vocal fold paralysis/paresis (VFP) is an uncommon but serious complication following esophagectomy. The objectives of this study were to: 1) identify the prevalence of VFP and associated complications after esophagectomy in the United States, and 2) determine the utilization and otolaryngology-head and neck surgery/speech-language pathology (OHNS/SLP) and predictors of such utilization in the management of these patients.

STUDY DESIGN

Retrospective database analysis.

METHODS

The National Inpatient Sample (NIS) represents a 20% stratified sample of discharges from US hospitals. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, patients undergoing esophagectomy between 2008 and 2013 were identified in the NIS. Subcohorts of patients with VFP and OHNS/SLP utilization were also identified. Weighted logistic regression models were used to compare binary outcomes such as complications; generalized linear models were used to compare total hospital charges and length of stay (LOS).

RESULTS

We studied 10,896 discharges, representing a weighted estimate of 52,610 patients undergoing esophagectomy. The incidence of VFP after esophagectomy was 1.96%. Compared to those without VFP, patients with VFP had a higher incidence of postoperative pneumonia, more medical complications, and were more likely to undergo tracheostomy; hospital charges and LOS were also higher. Of the patients with VFP, 35.0% received OHNS/SLP intervention.

CONCLUSIONS

VFP after esophagectomy is associated with postoperative complications, prolonged LOS, and higher hospital costs. OHNS/SLP intervention occurred in roughly one-third of postesophagectomy VFP patients, suggesting there may be opportunities for enhanced evaluation and management of these patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2815-2822, 2018.

Diagnostic value of intraoperative ultrasonography in assessing thoracic recurrent laryngeal nerve lymph nodes in patients with esophageal cancer

Backgroud

The incidence of recurrent laryngeal nerve (RLN) injury has increased due to RLN lymph node dissection. The aim of this study was to evaluate the ability of intraoperative ultrasonography (IU) to detect RLN nodal metastases in esophageal cancer patients.

Methods

Sixty patients with esophageal cancer underwent IU, computed tomography (CT), and endoscopic ultrasonography (EUS) to assess for RLN nodal metastasis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared.

Results

The sensitivities of IU, CT, and EUS in diagnosing right RLN nodal metastases were 71.4, 14.3, and 30.0%, respectively, and a significant difference among these three examinations was observed (χ2 = 10.077, P = .006). The specificities of IU, CT, and EUS for diagnosing right RLN nodal metastasis were 67.4, 97.8, and 95.0%, respectively, and a significant difference was observed (χ2 = 21.725, P < .001). No significant differences in either PPV or NPV were observed when diagnosing right RLN nodal metastases. For diagnosis of left RLN lymph nodal metastases, the sensitivities of IU, CT, and EUS were 91.7, 16.7, and 40.0% respectively. There was a significant difference among these diagnostic sensitivities (χ2 = 14.067, P = .001). The specificities of IU, CT, and EUS for diagnosis of left RLN nodal metastases were 79.2, 100, and 82.5%, respectively and a significant difference was observed (χ2 = 10.819, P = .004). No significant differences were observed in PPV or NPV for these examinations when diagnosing left RLN nodal metastases.

Conclusion

Intraoperative ultrasonography showed superior sensitivity compared with preoperative CT or EUS in detecting RLN lymph node metastasis in patients with thoracic esophageal cancer.

Diagnosis, assessment, and management of surgical complications following esophagectomy

Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.

Size of recurrent laryngeal nerve as a new risk factor for postoperative vocal cord paralysis

Recurrent laryngeal nerve paralysis (RLNP) is a frequent and serious complication following esophageal cancer surgery. Therefore, this study aims to evaluate the correlation between recurrent laryngeal nerve (RLN) size and RLNP. This was a retrospective study of esophageal cancer patients who underwent thoracoscopic esophagectomy from January 2012 to December 2014. Eighty-four patients were included in the primary analysis. Diameter of the RLN was measured using the digital video recording of surgical procedures by the ratio between scissor and RLN. For evaluation of vocal cord paralysis or paresis, indirect laryngoscopy was performed. Because RLNP more frequently occurs on the left side than the right, we evaluated the correlation between size of the left RLN and left RLNP. The median size of the left RLN was 1.51 mm. We found that the incidence of postoperative left RLNP (Clavien-Dindo classification ≥1) was significantly higher (71% vs. 24%; P < 0.001) in thin RLNs (≤1.5 mm) than in thick RLNs (>1.5 mm). Thin RLN (P < 0.001), female sex (P = 0.025), and being overweight (P = 0.034) were identified as significant independent risk factors for postoperative RLNP. RLNP more easily occurred when the RLN was thin. It is difficult to confirm occurrence of postoperative RLNP before and at extubation. Therefore, it is helpful to know its risk factors including size of RLN.

Minimally invasive injection laryngoplasty in the management of unilateral vocal cord paralysis after video-assisted mediastinal lymph adenectomy

Introduction

Video-assisted mediastinal lymphadenectomy (VAMLA) is a valuable tool for invasive staging of the mediastinum. Unilateral vocal cord paralysis (UVCP) may occur in patients following VAMLA and may result in secretion retention within the lungs, atelectasis and associated infectious situations such as pneumonia. Minimally invasive injection laryngoplasty (ILP) is the treatment of choice in UVCP.

Aim

To evaluate the efficacy and success of acute minimally invasive injection laryngoplasty for patients with UVCP following VAMLA.

Material and methods

Patients with the symptom of dysphonia following VAMLA were reviewed. All of the patients had UVCP according to the video laryngoscopy examination and had symptoms of aspiration and ineffective coughing. The Voice Handicap Index (VHI) questionnaire and maximum phonation time (MPT) were measured. Minimally invasive ILP was performed under general anesthesia with 1 cm of hyaluronic acid.

Results

There were 525 consecutive non-small cell lung cancer (NSCLC) patients who underwent VAMLA. Five (0.95%) of the patients had UVCP and were suffering from aspiration during oral intake and ineffective coughing reflex. Maximum phonation time (MFT) was measured before and after ILP, and the results were 7.1 ±1.6 and 11.1 ±2.3 s, respectively (p < 001). The Voice Handicap Index-10 (VHI-10) score was 30.4 ±4.7 and 13.4 ±3.5 (p < 0.01), respectively. Patients underwent surgical lung resection. There was no morbidity or mortality.

Conclusions

Unilateral vocal cord paralysis may occur as a complication of VAMLA. ILP may be an active tool for treating UVCP before anatomical lung resection to avoid potential morbidities. Successful management of this complication with multidisciplinary team work may encourage the use of VAMLA more frequently.

Clinical value of a prophylactic minitracheostomy after esophagectomy: analysis in patients at high risk for postoperative pulmonary complications

BACKGROUND

The aim of this study is to evaluate the clinical value of a prophylactic minitracheostomy (PMT) in patients undergoing an esophagectomy for esophageal cancer and to clarify the indications for a PMT.

METHODS

Ninety-four patients who underwent right transthoracic esophagectomy for esophageal cancer between January 2009 and December 2013 were studied. Short surgical outcomes were retrospectively compared between 30 patients at high risk for postoperative pulmonary complications who underwent a PMT (PMT group) and 64 patients at standard risk without a PMT (non-PMT group). Furthermore, 12 patients who required a delayed minitracheostomy (DMT) due to postoperative sputum retention were reviewed in detail, and risk factors related to a DMT were also analyzed to assess the indications for a PMT.

RESULTS

Preoperative pulmonary function was lower in the PMT group than in the non-PMT group: FEV1.0 (2.41 vs. 2.68 L, p = 0.035), and the proportion of patients with FEV1.0% <60 (13.3% vs. 0%, p = 0.009). No between-group differences were observed in the proportion of patients who suffered from postoperative pneumonia, atelectasis, or re-intubation due to respiratory failure. Of the 12 patients with a DMT, 11 developed postoperative pneumonia, and three required re-intubation due to severe pneumonia. Multivariate analysis revealed FEV1.0% <70% and vocal cord palsy were independent risk factors related to a DMT.

CONCLUSION

A PMT for high-risk patients may prevent an increase in the incidence of postoperative pneumonia and re-intubation. The PMT indications should be expanded for patients with vocal cord palsy or mild obstructive respiratory disturbances.

Perioperative outcomes of single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer

We developed an en bloc lymphadenectomy method in the upper mediastinum with a single-port mediastinoscopic cervical approach. This study was designed to evaluate the safety and efficacy of single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer. The perioperative outcomes of 60 patients with thoracic esophageal cancer who underwent this operation between March 2014 and June 2016 were retrospectively analyzed. The upper mediastinal dissection including lymphadenectomy along the left recurrent laryngeal nerve, using a left cervical approach, was performed with a single-port mediastinoscopic technique, which was used to improve the visibility and handling in the deep mediastinum around the aortic arch. The lymphadenectomy along the right recurrent laryngeal nerve was performed under direct vision using a right cervical approach. Bilateral cervical approaches were followed by hand-assisted laparoscopic transhiatal esophagectomy with en bloc lymphadenectomy in the middle and lower mediastinum. Tumors were mainly located in the middle thoracic esophagus (n = 33), and most tumors were squamous cell carcinoma (n = 58). Pretreatment diagnoses were stage I, 19; II, 13; III, 24; IV, 4. Preoperative chemotherapy was performed for 40 patients. The median operation time and blood loss were 363 minutes and 235 mL, respectively. There were two patients who underwent conversion to thoracotomy. Perioperative complications were evaluated and graded according to the Clavien-Dindo (CD) and the Esophagectomy Complications Consensus Group (ECCG) classifications. Postoperatively, pneumonia was observed in four patients (CD, Grade II, 2; Grade IIIb, 2), although vocal cord palsy was more frequent (ECCG, Type I, 12; Type III, 8). The median number of thoracic lymph nodes resected was 21, and the R0 resection rate was 95%. Single-port mediastinoscope-assisted transhiatal esophagectomy is feasible, in terms of perioperative outcomes, for a radical surgery for thoracic esophageal cancer, although its safety needs to be further demonstrated.

Impact of routine recurrent laryngeal nerve monitoring in prone esophagectomy with mediastinal lymph node dissection

BACKGROUND

The problem of recurrent laryngeal nerve (RLN) paralysis (RLNP) after radical esophagectomy remains unresolved. Several studies have confirmed that intraoperative nerve monitoring (IONM) of the RLN during thyroid surgery substantially decreases the incidence of RLN damage. This study tried to determine the feasibility and effectiveness of IONM of the RLN during thoracoscopic esophagectomy in the prone position for esophageal cancer.

METHODS

All 108 patients who underwent prone esophagectomy at Tohoku University Hospital between July 2012 and March 2015 were included in this study. We divided patients into two groups: a control group (No-Monitoring group, surgery without IONM; n = 54) and a study group (Monitoring group, surgery with IONM; n = 54). In Monitoring group, neural stimulation was performed for both RLNs before and after dissection in the thoracic procedure, then for RLNs and vagus nerves (VNs) in the cervical procedure. The feasibility of IONM in Monitoring group and early surgical outcomes were retrospectively compared with those in No-Monitoring group.

RESULTS

IONM could be performed for 47 cases (87.0%) in Monitoring group. Reasons for discontinuation were use of muscle relaxants (3 patients), change in thoracotomy procedure (2 patients), past rib bone fracture (1 patient), and allergic shock by transfusion (1 patient). Right RLNPs were identified postoperatively in 4 patients, and left RLNPs in 23 patients. IONM sensitivities were 92.7 and 88.0% for the right and left VNs, respectively. Incidences of postoperative RLNP, aspiration, and primary pneumonia did not differ significantly between groups.

CONCLUSIONS

This study confirmed the feasibility and safety of IONM of the RLN for thoracoscopic esophagectomy in the prone position. No significant differences in postoperative outcomes were seen between esophagectomy with and without IONM.

Recurrent laryngeal nerve injury after esophagectomy for esophageal cancer: incidence, management, and impact on short- and long-term outcomes

BACKGROUND

Recurrent laryngeal nerve (RLN) injury caused by esophagectomy may lead to postoperative morbidity, however data on long-term recovery are scarce. The aim of this study was to evaluate the consequences of RLN palsy (RLNP) in terms of pulmonary morbidity and long-term functional recovery.

METHODS

Patients who underwent a 3-stage transthoracic (McKeown) or a transhiatal esophagectomy for esophageal carcinoma in the University Medical Center Utrecht (UMCU) between January 2004 and March 2016 were included from a prospective database. Multivariable analyses were conducted to assess the association between RLNP and pulmonary complications and hospital stay. Data regarding long-term recovery were summarized using descriptive statistics.

RESULTS

Out of the 451 included patients, 47 (10%) were diagnosed with RLNP. Of the patients with RLNP, 34 (7%) had a unilateral lesion, 8 (2%) had a bilateral lesion, and in 5 (1%) the location of the lesion was unknown. The incidence of RLNP was 3/127 (2%) in the transhiatal group, and 44/324 (14%) in the McKeown group. RLNP after McKeown esophagectomy was associated with a higher incidence of pulmonary complications (OR 2.391; 95% CI 1.222-4.679; P=0.011), as well as a longer hospital stay (+4 days) (P=0.001). Of the RLNP patients with more than 6 months follow up almost half recovered fully {median follow-up of 17.5 [7-135] months}. Of the remainder, six required a surgical intervention and the others had residual symptoms.

CONCLUSIONS

RLNP after McKeown esophagectomy is associated with an increased pulmonary complication rate, longer hospital stay, and a moderate long-term recovery. Further studies are necessary that examine technologies, which may reduce RLNP incidence and contribute to the early detection and treatment of RLNP.

Continuous Intraoperative Neuromonitoring Study Using Pigs for the Prevention of Mechanical Recurrent Laryngeal Nerve Injury in Esophageal Surgery

PURPOSES

During esophageal surgery, clamping injury and injury associated with the use of energy devices are common mechanisms underlying intraoperative recurrent laryngeal nerve (RLN) damage. Recently, intraoperative neuromonitoring (IONM) has been applied to prevent RLN injury. This study was aimed at investigating the changes in the EMG signals associated with clamping injury of the RLN caused by picking up of the nerve with tweezers in domestic pigs.

METHODS

Six domestic pigs (12 RLNs) underwent continuous IONM (CIONM) by our original automated periodic vagal nerve stimulation method.

RESULTS

Our system can be used safely and accurately. The signals showed a decrease of the amplitude when the RLN was picked up and closed slowly by the double-action Maryland with jaw covers. If the clamp was released before the signal amplitude decreased to 50% of the baseline, the signal showed gradual recovery to the baseline in 12 ± 3 minutes.

CONCLUSION

Although there were limitations in our study using domestic pig, including the small sample size, our results are expected to contribute to a decrease in the incidence of RLN damage during esophageal surgery.

Preoperative computed tomography diagnosis of non-recurrent laryngeal nerve in patients with esophageal carcinoma

Background

The non‐recurrent laryngeal nerve (NRLN) is a rare but potentially serious anomaly that is commonly associated with the aberrant right subclavian artery (ARSA). It is easy to damage during surgical resection of esophageal cancer, leading to severe complications.

Methods

Preoperative enhanced thoracic computed tomography (CT) scans of 2697 patients with esophageal carcinoma treated in our hospital between January 2010 and December 2013 were examined. We classified the positional relationship between the right subclavian artery and the membranous wall of the trachea into two types and used this method to predicate NRLN by identifying ARSA.

Results

Twenty‐six patients (0.96%) were identified with ARSA, all of which were cases of NRLN by CT. NRLN was identified during surgery in the 26 patients, and a normal right recurrent laryngeal nerve was observed in 2671 patients. The ARSA was detected on the dorsal side of the membranous wall of the trachea in all 26 NRLN cases, while it was detected on the ventral side in all 2671 recurrent laryngeal nerve cases.

Conclusion

Enhanced CT scanning is a reliable method for predicting NRLN by identifying ARSA. Preoperative recognition of this nerve anomaly allows surgeons to avoid damaging the nerve and abnormal vessels during esophagectomy.