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Yang Y, Jiang C, Su Y, Pan J, Liu Z, Zhang H, Li Z. Occurrence and recovery of vocal cord paralysis after minimally invasive McKeown esophagectomy, risk factors, and clinical outcome. Surgery 2024:S0039-6060(24)00320-9. [PMID: 38890101 DOI: 10.1016/j.surg.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND This study aimed to observe the occurrence of recurrent laryngeal nerve injury after McKeown esophagectomy for esophageal squamous cell carcinoma, as well as its recovery and influencing factors within 7 months after surgery. METHODS From July 2020 to July 2021, among all patients who underwent minimally invasive McKeown esophagectomy, 90 patients who developed vocal cord paralysis after surgery were included in the study. These patients underwent endoscopic vocal cord function assessment every 1 to 2 months and continued until 7 months postoperatively. RESULTS Among all 388 patients undergoing esophagectomy, 23.2% (90/388) of patients suffered postoperative vocal cord paralysis. Left, right, and bilateral injuries were confirmed in 73 (81.1%), 12 (13.3%), and 5 patients (5.6%), respectively. With a median recovery time being 183 days, the cumulative overall recovery rate was 65.4% at 7 months, 68.6% for the left side, 55.6% for the right, and 20.0% for bilateral injuries. In multivariable analysis, cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be independent risk factors associated with non-recovery of vocal cord paralysis. CONCLUSIONS After intensive endoscopic follow-up, a cumulative vocal cord paralysis recovery rate of 65.4% within 7 months was observed in patients after minimally invasive McKeown esophagectomy. Cervical paraoesophageal lymph node dissection and conventional thoracoscopic-assisted esophagectomy were demonstrated to be risk factors hindering vocal cord paralysis recovery.
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Affiliation(s)
- Yuxin Yang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Chao Jiang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Yuchen Su
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Jie Pan
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Zhichao Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Hong Zhang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China
| | - Zhigang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, China.
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Baciewicz FA. The goose (oesophagus) still honks! Eur J Cardiothorac Surg 2024; 65:ezae146. [PMID: 38603612 DOI: 10.1093/ejcts/ezae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/05/2024] [Indexed: 04/13/2024] Open
Affiliation(s)
- Frank A Baciewicz
- Division of Cardiothoracic Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Harper Hospital, Detroit, MI, USA
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Kuo CT, Chiu CH, Fang TJ, Chao YK. Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study. Ann Surg Oncol 2024; 31:1546-1552. [PMID: 37989958 DOI: 10.1245/s10434-023-14560-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/22/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a serious complication of esophagectomy that affects the patient's phonation and the ability to prevent life-threatening aspiration events. The aim of this single-center, retrospective study was to investigate the clinical course of left RLN palsy and to identify the main prognostic factors for recovery. METHODS The study cohort consisted of 85 patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy. Vocal cord function was assessed in all participants through laryngoscopic examinations, both in the immediate postoperative period and during follow-up. Permanent palsy was defined as no evidence of recovery after 6 months. Univariate and multivariable logistic regression analyses were applied to evaluate the associations between different variables and the outcome of palsy. RESULTS Twenty-two (25.8%) patients successfully recovered from left RLN palsy. On multivariable logistic regression analysis, active smoking (odds ratio [OR] 0.335, p = 0.038) and the use of thoracoscopic surgery (vs. robotic surgery; OR 0.264, p = 0.028) were identified as independent unfavorable predictors for recovery from palsy. The estimated rates of recovery derived from a logistic regression model for patients harboring two, one, or no risk factors were 13.16%, 31.15-34.75%, and 61.39%, respectively. CONCLUSION Only one-quarter of patients who had developed left RLN palsy after minimally invasive McKeown esophagectomy were able to fully recover. Smoking habits and the surgical approach were identified as key determinants of recovery. Patients harboring adverse prognostic factors are potential candidates for early intervention strategies.
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Affiliation(s)
- Chun-Ting Kuo
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.
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Ishida H, Fukutomi T, Taniyama Y, Sato C, Okamoto H, Ozawa Y, Onodera Y, Koseki K, Unno M, Kamei T. Blood flow ratio in the gastric conduit measured by laser Doppler flowmetry: A predictor of anastomotic leakage after esophagectomy. Ann Gastroenterol Surg 2024; 8:234-242. [PMID: 38455484 PMCID: PMC10914705 DOI: 10.1002/ags3.12754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/10/2023] [Accepted: 10/30/2023] [Indexed: 03/09/2024] Open
Abstract
Background Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. Methods A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Results Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Conclusion Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.
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Affiliation(s)
- Hirotaka Ishida
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Toshiaki Fukutomi
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yusuke Taniyama
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Chiaki Sato
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Hiroshi Okamoto
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yohei Ozawa
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yu Onodera
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Ken Koseki
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Takashi Kamei
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
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Shiomi S, Yagi K, Iwata R, Yajima S, Okumura Y, Aikou S, Yamashita H, Nomura S, Seto Y. Lymphatic flow mapping using near-infrared fluorescence imaging with indocyanine green helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer not treated with neoadjuvant chemotherapy. Surg Endosc 2023; 37:8214-8226. [PMID: 37653159 PMCID: PMC10615981 DOI: 10.1007/s00464-023-10368-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Lymphatic flow mapping using near-infrared fluorescence (NIR) imaging with indocyanine green (ICG) has been used for the intraoperative prediction of lymph node metastasis in esophageal or esophagogastric junction cancer. However, a consistent method that yields sufficient diagnostic quality is yet to be confirmed. This study explored the diagnostic utility of our newly established lymphatic flow mapping protocol for predicting lymph node metastasis in patients with esophageal or esophagogastric junction cancer. METHODS We injected 0.5 mL of ICG (500 μg/mL) into the submucosal layer at four peritumoral points on the day before surgery for 54 patients. We performed lymphatic flow mapping intraoperatively using NIR imaging. After determining the NIR status and presence of metastases, evaluable lymph node stations on in vivo imaging and all resected lymph nodes were divided into four categories: ICG+meta+ (true positive), ICG+meta- (false positive), ICG-meta+ (false negative), and ICG-meta- (true negative). RESULTS The distribution of ICG+ and meta+ lymph node stations differed according to the primary tumor site. Sensitivity and specificity for predicting meta+ lymph nodes among ICG+ ones were 50% (95% CI 41-59%) and 75% (73-76%), respectively. Predicting meta+ lymph node stations among ICG+ stations improved these values to 66% (54-77%) and 77% (74-79%), respectively. Undergoing neoadjuvant chemotherapy was an independent risk factor for having meta+ lymph nodes with false-negative diagnoses (odds ratio 4.82; 95% CI 1.28-18.19). The sensitivity of our technique for predicting meta+ lymph nodes and meta+ lymph node stations in patients who did not undergo neoadjuvant chemotherapy was 79% (63-90%) and 83% (61-94%), respectively. CONCLUSION Our protocol potentially helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer undergoing esophagectomy who did not undergo neoadjuvant chemotherapy.
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Affiliation(s)
- Shinichiro Shiomi
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koichi Yagi
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Ryohei Iwata
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Division of Digestive Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shoh Yajima
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasuhiro Okumura
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Susumu Aikou
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
- Department of Surgery, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Hiroharu Yamashita
- Division of Digestive Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Sachiyo Nomura
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Yang Y, Li B, Xu X, Liu Z, Jiang C, Wu X, Yang Y, Li Z. Short-term and long-term effects of recurrent laryngeal nerve injury after robotic esophagectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107009. [PMID: 37562152 DOI: 10.1016/j.ejso.2023.107009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) was reported to have superiority in upper mediastinal lymph nodes dissection than traditional approach, but related injuries to recurrent laryngeal nerve (RLNI) cannot be avoided. Considering that there is no study centering on RLNI during robotic manipulation, this study aimed to investigate the impact of RLNI on the short-term and long-term outcomes after RAMIE. METHODS Patients with esophageal cancer (EC) who underwent RAMIE from June 2015 to July 2019 were collated from a prospectively maintained database. Short-term and long-term outcomes of RLNI were analyzed. RESULTS A total of 409 patients were included with the incidence of RLNI being 18.6% (76/409). A higher rate of postoperative pulmonary complications including pneumonia (P < 0.001) and acute respiratory distress syndrome (ARDS) (P = 0.041) was associated with RLNI, requiring more interventions for bronchoscopy airway suction (P < 0.001), tracheal reintubation (P = 0.013) and tracheostomy (P < 0.001). Patients with RLNI had a prolonged length of hospitalization and intensive care unit (ICU) stay (P < 0.001). With the median follow-up time of 48.7 (interquartile range [IQR]:27.6-60.9) months, recurrence in regional lymph nodes at mediastinum did not differ between groups (P = 0.351). Similarly, the Kaplan-Meier curves revealed no significant divergency for overall survival after RLNI (P = 0.452). CONCLUSIONS RLNI after robotic esophagectomy is a serious morbidity associated with an increased rate of pulmonary complications, prolonged length of hospitalization with limited influence on long-term prognosis.
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Affiliation(s)
- Yuxin Yang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinyi Xu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhichao Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao Jiang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolu Wu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhigang Li
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Fukutomi T, Taniyama Y, Sato C, Okamoto H, Niikawa H, Okada Y, Kamei T. A Case of Esophageal Cancer Treated by Thoracoscopic Esophagectomy after Bilateral Cadaveric Lung Transplantation. Ann Thorac Cardiovasc Surg 2023; 29:200-205. [PMID: 35082191 PMCID: PMC10466120 DOI: 10.5761/atcs.cr.21-00203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE With de novo cancer, esophagectomy after lung transplantation (LTx) can be challenging because of intrathoracic adhesions, delayed wound healing, and postoperative pulmonary complications, which might be lethal. CASE PRESENTATION A 52-year-old woman with esophageal cancer had undergone bilateral LTx for end-stage diffuse panbronchiolitis at 50 years of age. Thoracoscopic esophagectomy was performed. Bilateral bronchial arteries and subcarinal and bilateral bronchial lymph nodes were preserved to maintain blood supply to the transplanted bronchi. No ischemic changes were observed in either bronchi. The patient's postoperative course was uneventful. Although she underwent chemoradiation therapy for recurrence at the left cervical paraesophageal lymph node, she remains alive with good disease control and well-maintained respiratory function. CONCLUSION Minimally invasive surgery with careful attention to blood supply to the transplanted bronchi was useful for treating esophageal cancer after LTx.
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Affiliation(s)
- Toshiaki Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Hiromichi Niikawa
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Miyagi, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Application of Intraoperative Neuromonitoring (IONM) of the Recurrent Laryngeal Nerve during Esophagectomy: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12020565. [PMID: 36675495 PMCID: PMC9860817 DOI: 10.3390/jcm12020565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/24/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
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.
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Hsu PK, Lee YY, Chuang LC, Wu YC. Lymph Node Dissection for Esophageal Squamous Cell Carcinoma. Thorac Surg Clin 2022; 32:497-510. [DOI: 10.1016/j.thorsurg.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Yuda M, Nishikawa K, Ishikawa Y, Takahashi K, Kurogochi T, Tanaka Y, Matsumoto A, Tanishima Y, Mitsumori N, Ikegami T. Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy. Surg Endosc 2022; 36:3957-3964. [PMID: 34494155 DOI: 10.1007/s00464-021-08716-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Masami Yuda
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa-shi, Chiba, 277-8567, Japan.
| | - Katsunori Nishikawa
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshitaka Ishikawa
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Kurogochi
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yujiro Tanaka
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Matsumoto
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichiro Tanishima
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norio Mitsumori
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Yan HJ, Mao WJ, Yu RX, Jiang KY, Huang H, Zong ZD, Qian QC, Guo XG, Wen HY, Tian D. Preoperative Clinical Characteristics Predict Recurrent Laryngeal Nerve Lymph Node Metastasis and Overall Survival in Esophageal Squamous Cell Carcinoma: A Retrospective Study With External Validation. Front Oncol 2022; 12:859952. [PMID: 35433473 PMCID: PMC9008727 DOI: 10.3389/fonc.2022.859952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Recurrent laryngeal nerve (RLN) lymph node metastasis (LNM) is not rare in patients with esophageal squamous cell carcinoma (ESCC). We aimed to develop and externally validate a preoperative nomogram using clinical characteristics to predict RLN LNM in patients with ESCC and evaluate its prognostic value. Methods A total of 430 patients with ESCC who underwent esophagectomy with lymphadenectomy of RLN LNs at two centers between May 2015 and June 2019 were reviewed and divided into training (center 1, n = 283) and external validation cohorts (center 2, n = 147). Independent risk factors for RLN LNM were determined by multivariate logistic regression, and a nomogram was developed. The performance of the nomogram was assessed in terms of discrimination, calibration, clinical usefulness, and prognostic value. The nomogram was internally validated by the bootstrap method and externally validated by the external validation cohort. Results Multivariate analysis indicated that clinical T stage (P <0.001), endoscopic tumor length (P = 0.003), bioptic tumor differentiation (P = 0.004), and preoperative carcinoembryonic antigen level (P = 0.001) were significantly associated with RLN LNM. The nomogram had good discrimination with the area under the curve of 0.770 and 0.832 after internal and external validations. The calibration curves and decision curve analysis confirmed the good calibration and clinical usefulness of this model. High-risk of RLN LNM predicted by the nomogram was associated with worse overall survival in the external validation cohort (P <0.001). Conclusion A nomogram developed by preoperative clinical characteristics demonstrated a good performance to predict RLN LNM and prognosis for patients with ESCC.
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Affiliation(s)
- Hao-Ji Yan
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China.,College of Medical Imaging, North Sichuan Medical College, Nanchong, China
| | - Wen-Jun Mao
- Department of Cardiothoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Rui-Xuan Yu
- Department of Thoracic Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kai-Yuan Jiang
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Heng Huang
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Zheng-Dong Zong
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Qin-Chun Qian
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Xiao-Guang Guo
- Department of Pathology, Nanchong Central Hospital, Nanchong, China
| | - Hong-Ying Wen
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Dong Tian
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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12
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Tu DH, Qu R, Ping W, Yang G, Ma X, Fu X, Cai Y. Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis. Langenbecks Arch Surg 2022; 407:1891-1900. [PMID: 35314875 DOI: 10.1007/s00423-022-02475-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure. METHODS The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups. RESULTS A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32 months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15 months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups. CONCLUSIONS Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.
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Affiliation(s)
- De-Hao Tu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Rirong Qu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Wei Ping
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Guang Yang
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China
| | - Xiaoling Ma
- Department of Radiology, Tongji Hospital Tongji Medical College Huazhong University of Science and Technology, Wuhan, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China.
| | - Yixin Cai
- Department of Thoracic Surgery, Tongji Hospital Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Wuhan, 430030, China.
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13
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Sugase T, Miyata H, Sugimura K, Kanemura T, Takeoka T, Yamamoto M, Shinno N, Hara H, Omori T, Yano M. Risk factors and long‐term postoperative outcomes in patients with postoperative dysphagia after esophagectomy for esophageal cancer. Ann Gastroenterol Surg 2022; 6:633-642. [PMID: 36091303 PMCID: PMC9444858 DOI: 10.1002/ags3.12566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Takahito Sugase
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Hiroshi Miyata
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Keijiro Sugimura
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Takashi Kanemura
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Tomohira Takeoka
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Masaaki Yamamoto
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Naoki Shinno
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Hisashi Hara
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Takeshi Omori
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
| | - Masahiko Yano
- Department of Digestive Surgery Osaka International Cancer Institute Osaka Japan
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14
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Zhang S, Liu Q, Li B, Jia M, Cai X, Yang W, Liao S, Wu Z, Cheng C, Fu J. 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. Cancer Med 2022; 11:1617-1629. [PMID: 35174645 PMCID: PMC8986140 DOI: 10.1002/cam4.4399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/17/2021] [Accepted: 10/15/2021] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Shuishen Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Qianwen Liu
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Department of Thoracic Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
| | - Bin Li
- Biostatistics Team, Clinical Trials Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Minghan Jia
- Department of Breast Cancer, Guangdong Provincial People's Hospital Cancer Center, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xiaoli Cai
- Department of Medical Ultrasonics, First Affiliated Hospital of Jinan University, Guangzhou, People's Republic of China
| | - Weixiong Yang
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Shufen Liao
- The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Zhongkai Wu
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, People's Republic of China
| | - Chao Cheng
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Jianhua Fu
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.,Department of Thoracic Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
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15
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Wang X, Guo H, Hu Q, Ying Y, Chen B. Efficacy of Intraoperative Recurrent Laryngeal Nerve Monitoring During Thoracoscopic Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-Analysis. Front Surg 2021; 8:773579. [PMID: 34805262 PMCID: PMC8595130 DOI: 10.3389/fsurg.2021.773579] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/07/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Baofu Chen
- Department of Thoracic and Cardiovascular Surgery, Affiliated Taizhou Hospital of Wenzhou Medical University, Taizhou, China
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16
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Pai CP, Hsu PK, Chien LI, Huang CS, Hsu HS. Clinical outcome of patients after recurrent laryngeal nerve lymph node dissection for oesophageal squamous cell carcinoma. Interact Cardiovasc Thorac Surg 2021; 34:393-401. [PMID: 34734236 PMCID: PMC8860418 DOI: 10.1093/icvts/ivab293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 08/26/2021] [Accepted: 09/20/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Recurrent laryngeal nerve lymph node dissection (LND) has been incorporated into oesophagectomy for patients with oesophageal squamous cell carcinoma, but with uncertain oncological efficacy. METHODS The data of patients with oesophageal squamous cell carcinoma, including who underwent upfront surgery (surgery group) and those who received neoadjuvant therapy followed by surgery (neoadjuvant chemoradiotherapy group), were retrospectively examined. The overall survival (OS) and disease-free survival (DFS) were compared between patients with and without recurrent laryngeal nerve LND. RESULTS Among the 312 patients, no significant differences were found in 3-year OS and DFS between patients with and without recurrent laryngeal nerve LND in the entire cohort (OS: 57% vs 52%, P = 0.33; DFS: 47% vs 41%, P = 0.186), or the surgery group (n = 173, OS: 69% vs 58%, P = 0.43; DFS: 52% vs. 48%, P = 0.30) and the neoadjuvant chemoradiotherapy group (n = 139, OS: 44% vs 43%, P = 0.44; DFS: 39% vs 32%, P = 0.27). However, among patients with clinical positive recurrent laryngeal nerve lymph node involvement before treatment, there was significant OS and DFS differences between patients with and without recurrent laryngeal nerve LND (OS: 62% vs 33%, P = 0.029; DFS: 49% vs 26%, P = 0.031). CONCLUSIONS Recurrent laryngeal nerve LND is not a significant prognostic factor in patients with oesophageal squamous cell carcinoma; however, it is associated with better outcomes in patients with pre-treatment radiological evidence of recurrent laryngeal nerve lymph node involvement.
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Affiliation(s)
- Chu-Pin Pai
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling-I Chien
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Sheng Huang
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Han-Shui Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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17
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Robot-Assisted Versus Conventional Minimally Invasive Esophagectomy for Resectable Esophageal Squamous Cell Carcinoma: Early Results of a Multicenter Randomized Controlled Trial: the RAMIE Trial. Ann Surg 2021; 275:646-653. [PMID: 34171870 DOI: 10.1097/sla.0000000000005023] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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18
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Zhang G, Li Y, Wang Q, Zheng H, Yuan L, Gao Z, Li J, Li X, Zhao S. Development of a prediction model for the risk of recurrent laryngeal nerve lymph node metastasis in thoracolaparoscopic esophagectomy with cervical anastomosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:990. [PMID: 34277790 PMCID: PMC8267307 DOI: 10.21037/atm-21-2374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/09/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuanqi Li
- Xiangya School of Public Health, Central South University, Changsha, China
| | - Qian Wang
- The Nursing Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huiwen Zheng
- The Nursing Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lulu Yuan
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Gao
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jindong Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Song Zhao
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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19
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Chao YK, Tsai CY, Illias AM, Chen CY, Chiu CH, Chuang WY. A standardized procedure for upper mediastinal lymph node dissection improves the safety and efficacy of robotic McKeown oesophagectomy. Int J Med Robot 2021; 17:e2244. [PMID: 33591632 DOI: 10.1002/rcs.2244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a common complication of upper mediastinal lymph node dissection (UMLND) in the context of oesophageal cancer surgery. In an effort to reduce its occurrence, we developed a standardised surgical procedure that allows flexible suspension of the left RLN during robotic McKeown oesophagectomy. PATIENTS AND METHODS Patients who received robotic McKeown oesophagectomy for cancer were divided into two groups (pre and poststandardisation). Perioperative outcomes were retrospectively compared. RESULTS The pre and poststandardisation groups consisted of 44 and 42 patients, respectively. There were no significant intergroup differences in terms of number of dissected lymph nodes. Compared with the prestandardisation group, patients treated after standardisation had a markedly lowered incidence of left RLN palsy (20.5% vs. 4.8%, respectively, p = 0.029) and a reduced mean thoracic operating time (161.05 vs. 131 min, respectively, p < 0.001). CONCLUSION Our standardised surgical approach is efficient and may increase the safety of UMLND.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Amina M Illias
- Department of Anesthesiology, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Yu Chuang
- Department of Pathology, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
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20
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Qu R, Tu D, Ping W, Fu X. The Impact of the Recurrent Laryngeal Nerve Injury on Prognosis After McKeown Esophagectomy for ESCC. Cancer Manag Res 2021; 13:1861-1868. [PMID: 33658850 PMCID: PMC7917328 DOI: 10.2147/cmar.s298228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/02/2021] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Rirong Qu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Dehao Tu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Wei Ping
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
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21
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Fujimoto D, Taniguchi K, Kobayashi H. Intraoperative neuromonitoring during prone thoracoscopic esophagectomy for esophageal cancer reduces the incidence of recurrent laryngeal nerve palsy: a single-center study. Updates Surg 2021; 73:587-595. [PMID: 33415692 DOI: 10.1007/s13304-020-00967-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/27/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Daisuke Fujimoto
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki-city, Kanagawa, 213-8507, Japan.
| | - Keizo Taniguchi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki-city, Kanagawa, 213-8507, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-ku, Kawasaki-city, Kanagawa, 213-8507, Japan
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Wang Z, Mao Y, Gao S, Li Y, Tan L, Daiko H, Liu S, Chen C, Koyanagi K, He J. Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy. Ann N Y Acad Sci 2020; 1481:20-29. [PMID: 32671860 DOI: 10.1111/nyas.14427] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/29/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
Until now, neoadjuvant therapy plus surgical resection of the primary tumor and potential metastatic lymph nodes (LNs) has been the current optimal treatment for locally advanced thoracic esophageal cancer (EC). LN metastasis is one of the most negative prognostic factors for thoracic esophageal squamous cell carcinoma (ESCC). However, the extent of LN dissection for thoracic ESCC has long been controversial worldwide. LNs along the recurrent laryngeal nerve (RLN) were reported to have the highest frequency of metastases in thoracic ESCC, so lymphadenectomy along the bilateral RLN is necessary but quite challenging because of a high frequency of recurrent nerve palsy and related postoperative complications. With the development of minimally invasive devices and techniques in recent years, minimally invasive esophagectomy (MIE) has been widely applied in EC surgery. The topics of what the optimal extent of lymphadenectomy is and how the recurrent nerve should be well protected during MIE have been debated in recent years. The purpose of our review is specifically to address the patterns of LN metastasis, the extent of LN dissection, and the protection of the RLN in MIE for thoracic ESCC.
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Affiliation(s)
- Zhen Wang
- Department of Thoracic Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yousheng Mao
- Department of Thoracic Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yin Li
- Department of Thoracic Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hiroyuki Daiko
- Esophageal Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shuoyan Liu
- Department of Thoracic Surgery, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Tokyo, Japan
| | - Jie He
- Department of Thoracic Surgery, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Yang F, Zou L, Li L, Zou Q, Chen P, Sun H, Liu X, Xu X. Effect of Chin-down-plus-larynx-tightening maneuver on swallowing function after minimally invasive esophagectomy: A randomized controlled trail. Cancer Med 2020; 9:5889-5898. [PMID: 32627975 PMCID: PMC7433833 DOI: 10.1002/cam4.3280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/21/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Background The incidence of swallowing abnormality was high after minimally invasive esophagectomy (MIE) for esophageal cancer (EC). Few reports, however, focused on interventions for dysphagia after esophagectomy. Aim The purpose of this research was to estimate the effect of Chin‐down‐plus‐larynx‐tightening maneuver on swallowing function for patients receiving esophagectomy. Method This was a 2‐arm, parallel‐group, single‐blind randomized clinical trial, performed in patients suffered from EC from November 2018 to January 2020. Patients were randomly assigned to the intervention group (IG) or the control group (CG). The participants in CG received routine care, and the IG received Chin‐down‐plus‐larynx‐tightening maneuver during feeding. The incidence of choking cough, swallowing function, and dietary outcomes were evaluated before and after intervention for 7 days. Results A total of 237 EC cases were enrolled and randomized to the IG (n = 118) or CG (n = 119). There was no significant difference between the two groups in terms of demographic and clinical characteristics. Postoperative choking cough occurred in 5 of 118 cases (4.24%) in IG and 18 of 119 cases (19.4%) in CG, the differences showed statistically significant (P < .001). The analysis showed that the participants in the IG compared with the CG have more total caloric intake of 24 hours and higher K/R (the ratio of calories oral achieved to total calories required of body) significantly from D1 to D7 of intervention (P < .05). Conclusion The findings suggest that the Chin‐down‐plus‐larynx‐tightening maneuver can improve swallowing function recovery and oral total food intake and calories in EC patients undergoing MIE.
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Affiliation(s)
- Funa Yang
- Nursing Department, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Limin Zou
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiyun Zou
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Peinan Chen
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xianben Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxia Xu
- Nursing Department, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
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Luo R, He Z, Xu Y, Zhu Z. Comparison of the surgical outcomes of McKeown minimally invasive esophagectomy and Ivor-Lewis esophagectomy for the treatment of middle esophageal cancer: A single-center retrospective study. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2020. [DOI: 10.1016/j.lers.2020.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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25
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Lai G, Guo N, Jiang Y, Lai J, Li Y, Lai R. Duration of one-lung ventilation as a risk factor for postoperative pulmonary complications after McKeown esophagectomy. TUMORI JOURNAL 2020; 106:47-54. [DOI: 10.1177/0300891619900805] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective:To assess whether the duration of one-lung ventilation (OLV) affects postoperative pulmonary complications after McKeown esophagectomy for esophageal cancer.Methods:A retrospective analysis of data stored in a database for esophageal cancer was carried out to identify predictors of postoperative pulmonary complications in patients undergoing McKeown esophagectomy at Sun Yat-sen University Cancer Center between 2010 and 2012.Results:Patients in the OLV ⩾150 minutes group had a higher incidence of postoperative pulmonary complications than those in the OLV <150 minutes group (18.0% vs 7.3%, p < 0.001). Among them, the number of patients who developed pneumonia and atelectasis was also significantly higher (9.0% vs 4.1% [ p = 0.031] and 8.7% vs 3.7% [ p = 0.018] for the OLV ⩾150 minutes group vs OLV <150 minutes group, respectively). OLV ⩾150 minutes was associated with a prolonged hospital stay (24.2 ± 9.7 vs 21.5 ± 9.2 days, p = 0.001). Multivariate analysis revealed that history of diabetes (odds ratio [OR], 3.56; 95% confidence interval [CI], 1.65–7.68; p = 0.001), chronic obstructive pulmonary disease (OR, 10.65; 95% CI, 5.65–20.08; p < 0.001), and OLV ⩾150 minutes (OR, 3.80; 95% CI, 1.97–7.31; p < 0.001) were independent predictors of postoperative pulmonary complications.Conclusion:Long duration of OLV appears to be an important risk factor for postoperative pulmonary complications after McKeown esophagectomy. OLV <150 minutes appears to be the better approach for thoracic surgery. Lung protective measures should be taken when prolonged OLV is anticipated.
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Affiliation(s)
- Guozhong Lai
- Department of Anesthesiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Na Guo
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Guangdong Esophageal Cancer Institute, Guangzhou, China
| | - Yu Jiang
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jielan Lai
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yi Li
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Renchun Lai
- Department of Anesthesiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Sato S, Nagai E, Taki Y, Watanabe M, Takagi M. Video-assisted esophagectomy using a port-free organ retractor for the prevention of laryngeal nerve paralysis. Asian J Endosc Surg 2020; 13:127-130. [PMID: 30663243 DOI: 10.1111/ases.12684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/14/2018] [Accepted: 12/02/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Recurrent laryngeal nerve (RLN) paralysis is a major complication of esophageal cancer surgery. The free jaw clip (FJ clip) was developed as an organ-retracting device, and it can also reduce the number of ports required during surgery. Here, we describe a new technique for lymphadenectomy along the left RLN using the FJ clip. MATERIALS AND SURGICAL TECHNIQUE After the middle and lower mediastinal lymph nodes were dissected, the upper esophagus and other tissues, including the lymph nodes and left RLN, were retracted by cutting the tracheal arteries between the esophagus and trachea and then pulling the upper esophagus to the dorsal side with the FJ clip. The esophagus was transected at the upper mediastinum, and the proximal esophagus was drawn by the FJ clip. This technique helped provide a good field of view during lymphadenectomy along the left RLN. The data of nine consecutive patients who underwent video-assisted esophagectomy in the left lateral decubitus position by the same surgeon were reviewed. Postoperative left RLN paralysis occurred in only one patient in whom the RLN could not be preserved. DISCUSSION Given the excellent short-term outcomes with respect to left RLN paralysis, lymphadenectomy along the left RLN using the FJ clip was safe and feasible.
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Affiliation(s)
- Shinsuke Sato
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Erina Nagai
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Yusuke Taki
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Masaya Watanabe
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Masakazu Takagi
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
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Chao YK, Chiu CH, Liu YH. Safety and oncological efficacy of bilateral recurrent laryngeal nerve lymph-node dissection after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma: a propensity-matched analysis. Esophagus 2020; 17:33-40. [PMID: 31428901 PMCID: PMC7223830 DOI: 10.1007/s10388-019-00688-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/13/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND We sought to evaluate the safety and oncological efficacy of bilateral recurrent laryngeal nerve (RLN) lymph-node dissection (LND) in patients with esophageal squamous cell carcinoma (ESCC) who had undergone neoadjuvant chemoradiotherapy (nCRT). METHODS We retrospectively examined the records of ESCC patients who were judged to be ycN-RLN(-) following nCRT. Patients were divided into two groups according to the extent of LND [standard two-field LND (STL group) versus total two-field LND (TTL group)]. Only lower mediastinal and upper abdominal lymph nodes were removed in the STL group. In addition to the standard procedure, patients in the TTL group underwent resection of upper mediastinal lymph nodes located along the bilateral RLN. Using propensity score matching, 29 pairs were identified and compared with regard to perioperative complications, lymph-node metastases rates, overall survival (OS), and disease-specific survival (DSS). RESULTS No significant intergroup differences were identified in terms of in-hospital mortality and morbidity. Metastases to the RLN lymph nodes were identified in 20.7% (6/29) of TTL patients, being the only site of lymph-node metastases in three of them. TTL was associated with lower upper mediastinal lymph-node recurrence rate (6.5%) compared with STL (21.5%, p = 0.134), although the overall recurrence rate was similar (STL, 44.8% versus TTL, 46.4%). No significant intergroup differences were also evident with regard to 3-year DSS and OS rates. CONCLUSIONS RLN LND can be safely performed in ESCC patients who had undergone nCRT, ultimately resulting in an improved local control, and should be practiced as part of the surgical routine.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan.
| | - Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyüan, Taiwan
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Yu Y, Li Y, Lu Y, Hua X, Ma H, Li H, Wei X, Zhang J, Chen X, Liu Q, Zhu Z, Xu L, Zhang R, Sun H, Wang Z. Chin-down-plus-larynx-tightening maneuver improves choking cough after esophageal cancer surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:376. [PMID: 31555690 DOI: 10.21037/atm.2019.07.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Yongkui Yu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Yin Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China.,Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Yingmin Lu
- Department of Thoracic Surgery, The Zhengzhou Center Hospital Affiliated to Zhengzhou University, Zhengzhou 450000, China
| | - Xionghuai Hua
- Department of Thoracic Surgery, He'nan Chest Hospital, Zhengzhou 450000, China
| | - Haibo Ma
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Haomiao Li
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Xiufeng Wei
- Department of Thoracic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang 453000, China
| | - Jun Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Xiankai Chen
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Qi Liu
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Zhengshuai Zhu
- Department of Thoracic Surgery, Nanyang Central Hospital, Nanyang 473000, China
| | - Lei Xu
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing 100000, China
| | - Ruixiang Zhang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Haibo Sun
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
| | - Zongfei Wang
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450000, China
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Evolving changes of minimally invasive esophagectomy: a single-institution experience. Surg Endosc 2019; 34:2503-2511. [PMID: 31385074 DOI: 10.1007/s00464-019-07057-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/31/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Initial adoption of minimally invasive esophagectomy (MIE) began in the late 1990s but its surgical technique, perioperative management, and outcome continues to evolve. METHODS The aim of this study was to examine the evolving changes in the technique, outcome, and new strategies in management of postoperative leaks after MIE was performed at a single institution over a two-decade period. A retrospective chart review of 75 MIE operations was performed between November 2011 and September 2018 and this was compared to the initial series of 104 MIE operations performed by the same group between 1998 and 2007. Operative technique, outcomes, and management strategies of leaks were compared. RESULTS There were 65 males (86.7%) with an average age of 61 years. The laparoscopic/thoracoscopic Ivor Lewis esophagectomy became the preferred MIE approach (49% of cases in the initial vs. 95% in the current series). Compared to the initial case series, there was no significant difference in median length of stay (8 vs. 8 days), major complications (12.5% vs. 14.7%, p = 0.68), incidence of leak (9.6% vs. 10.6%, p = 0.82), anastomotic stricture (26% vs. 32.0%, p = 0.38), or in-hospital mortality (2.9% vs. 2.6%, p = 0.47). Management of esophageal leaks has changed from primarily thoracotomy ± diversion initially (50% of leak cases) to endoscopic stenting ± laparoscopy/thoracoscopy currently (87.5% of leak cases). CONCLUSION In a single-institutional series of MIE over two decades, there was a shift toward a preference for the laparoscopic/thoracoscopic Ivor Lewis approach with similar outcomes. The management of postoperative leaks drastically changed with predilection toward minimally invasive option with endoscopic drainage and stenting.
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Xu J, Zheng B, Zhang S, Zeng T, Chen H, Zheng W, Chen C. The clinical significance of the intraoperative pathological examination of bilateral recurrent laryngeal nerve lymph nodes using frozen sections in cervical field lymph node dissection of thoracic esophageal squamous cell carcinoma. J Thorac Dis 2019; 11:3525-3533. [PMID: 31559059 DOI: 10.21037/jtd.2019.07.59] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The aim of this study was to evaluate intraoperative pathological examination of the left and right recurrent laryngeal nerve lymph nodes (LNs) using frozen section as a predictor of cervical LN metastasis. Methods Retrospectively collected data from 69 patients with esophageal squamous cell carcinoma who had undergone intraoperative pathological examination of the left and right recurrent laryngeal nerve LNs using frozen sections and three-field LN dissection in the Fujian Medical University Union Hospital from December 2015 to April 2018, was used to explore the relationship between recurrent laryngeal nerve LN metastasis and cervical LN metastasis and to determine whether cervical-field LN dissection should be performed in patients with thoracic esophageal cancer. Results In the entire cohort, 15.9% (11/69) of patients had metastasis in the cervical LNs. We detected 1,195 cervical LN, with an average of 17.3 LN dissections per patient; 28 (2.3%) cases had LN metastasis. Patients with recurrent laryngeal nerve LN metastasis tended to have a high incidence of cervical LN metastasis (P=0.017). Multivariate analysis showed that left recurrent laryngeal nerve LN metastasis was the only independent risk factor for cervical LN metastasis (P=0.02). The incidence of postoperative pulmonary infection was 18.8% (13/69), chylothorax was 2.9% (2/69), anastomotic leakage was 2.9% (2/69), and hoarseness was 8.7% (6/69) for the entire cohort. There was no significant increase in complications compared with patients with 2-field LN dissection in our hospital during the same period. Additional studies are necessary to establish postoperative locoregional recurrence rates and long-term survival. Conclusions Intraoperative pathological examination of left recurrent laryngeal nerve LN using frozen sections has some prognostic value in predicting cervical LN metastasis and it can be an indicator for the selection of cervical-field dissection in thoracic esophageal carcinoma.
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Affiliation(s)
- Jinxin Xu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Bin Zheng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Shuliang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Taidui Zeng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Hao Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Wei Zheng
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
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Liu Y, Zou ZQ, Xiao J, Zhang M, Yuan L, Zhao XG. A nomogram prediction model for recurrent laryngeal nerve lymph node metastasis in thoracic oesophageal squamous cell carcinoma. J Thorac Dis 2019; 11:2868-2877. [PMID: 31463116 DOI: 10.21037/jtd.2019.06.46] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Yu Liu
- Department of Thoracic Surgery, the Second Hospital of Shandong University, Jinan 250033, China.,Department of Thoracic Surgery, the 960th Hospital of People's Liberation Army of China, Jinan 250000, China
| | - Zhi-Qiang Zou
- Department of Thoracic Surgery, the 960th Hospital of People's Liberation Army of China, Jinan 250000, China
| | - Juan Xiao
- Center of Evidence-Based Medicine, Institute of Medical Sciences, the Second Hospital of Shandong University, Jinan 250033, China
| | - Mei Zhang
- Department of Thoracic Surgery, the 960th Hospital of People's Liberation Army of China, Jinan 250000, China
| | - Lei Yuan
- Department of Thoracic Surgery, the 960th Hospital of People's Liberation Army of China, Jinan 250000, China
| | - Xiao-Gang Zhao
- Department of Thoracic Surgery, the Second Hospital of Shandong University, Jinan 250033, China
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Koterazawa Y, Oshikiri T, Takiguchi G, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Nakamura T, Fujino Y, Tominaga M, Suzuki S, Kakeji Y. Prophylactic Cervical Lymph Node Dissection in Thoracoscopic Esophagectomy for Esophageal Cancer Increases Postoperative Complications and Does Not Improve Survival. Ann Surg Oncol 2019; 26:2899-2904. [DOI: 10.1245/s10434-019-07499-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 01/02/2023]
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Chiu CH, Wen YW, Chao YK. Lymph node dissection along the recurrent laryngeal nerves in patients with oesophageal cancer who had undergone chemoradiotherapy: is it safe? Eur J Cardiothorac Surg 2019; 54:657-663. [PMID: 29608683 DOI: 10.1093/ejcts/ezy127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/03/2018] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan.,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
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Influence of Preoperative Oropharyngeal Microflora on the Occurrence of Postoperative Pneumonia and Survival in Patients Undergoing Esophagectomy for Esophageal Cancer. Ann Surg 2019; 272:1035-1043. [PMID: 30946087 DOI: 10.1097/sla.0000000000003287] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to clarify the correlation between oropharyngeal microflora and postoperative complications as well as long-term survival after esophagectomy. BACKGROUND Although the oral cavity is known to be a potential reservoir for pathogens, the influence of abnormal oropharyngeal microflora on the outcomes of patients undergoing esophagectomy remains unknown. METHODS This study included 675 patients who underwent esophagectomy between 2007 and 2014. Saliva samples from the oropharynx were collected 2 days before the operation. There were 442 patients with indigenous flora (Ind group) and 233 with allopatric flora. Among the patients with allopatric flora, 140 had antibiotic-sensitive microbes only (Allo-S group) while 93 had different types of antibiotic-resistant microbes (Allo-R group). We investigated the correlation between the types of oropharyngeal microflora and the incidence of postoperative complications as well as long-term outcomes. RESULTS Sixteen microbes could be cultivated from the saliva samples. The incidence of postoperative pneumonia in the Allo-S and Allo-R groups was significantly higher than in the Ind group (P < 0.001). In addition, acute respiratory distress syndrome was more often observed in the Allo-R group than in the other groups (P = 0.002). A significantly higher rate of antibiotic use and longer hospital stays were observed in the Allo-R group compared with the Ind group. Multivariate logistic regression analysis revealed that the presence of allopatric antibiotic-resistant microbes in the oropharynx was an independent risk factor for postoperative pneumonia (odds ratio, 3.93; 95% confidence interval, 2.41-6.42). The overall survival was significantly poorer in the Allo-R group than in the other groups. CONCLUSIONS Preoperative oropharyngeal culture is a simple and low-cost method that can predict both the occurrence of postoperative pneumonia and poor prognosis after esophagectomy.
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Kim MH, Noh J, Pyun SB. Comparison of Clinical Characteristics Between Patients With Different Causes of Vocal Cord Immobility. Ann Rehabil Med 2017; 41:1019-1027. [PMID: 29354579 PMCID: PMC5773422 DOI: 10.5535/arm.2017.41.6.1019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/27/2017] [Indexed: 11/05/2022] Open
Abstract
Objective To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI). Methods The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group. Results Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched 'e' sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched 'e' sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018). Conclusion In patients with suspected vocal cord palsy, impaired high pitched 'e' sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.
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Affiliation(s)
- Min-Hyun Kim
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
| | - Junsoo Noh
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea
| | - Sung-Bom Pyun
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, Korea.,Brain Convergence Research Center, Korea University Anam Hospital, Seoul, Korea
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Kitagawa H, Namikawa T, Iwabu J, Fujisawa K, Kobayashi M, Hanazaki K. Comparison between neck-first approach and thoracic approach during thoracoscopic esophagectomy. Langenbecks Arch Surg 2017; 402:1159-1165. [PMID: 29116434 DOI: 10.1007/s00423-017-1637-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/01/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aimed to compare the outcomes of the prior cervical and thoracic approaches of thoracoscopic esophagectomy in the prone position for esophageal cancer. METHODS We reviewed the records of 103 consecutive patients who underwent thoracoscopic esophagectomy in the prone position for esophageal cancer. Seventy-four patients underwent the prior cervical approach (Cervical group); the other 29 underwent the thoracic approach (Thoracic group). The perioperative outcomes of the two groups were compared. RESULTS Total operative time and volume of blood loss were not different between the two groups, but the median thoracoscopic time was significantly longer in the Thoracic group than in the Cervical group (296 vs. 210 min; P < 0.001). The incidence of recurrent nerve palsy was not different; however, the incidence of the postoperative pneumonia tended to be higher in the Thoracic group than in the Cervical group (20.7 vs. 10.8%; P = 0.188), and the duration of postoperative hospital stay was significantly longer in the Thoracic group than in the Cervical group (22 vs. 17 days; P = 0.032). CONCLUSION Patients who underwent thoracoscopic esophagectomy in the prone position via the prior cervical approach had better short-term outcomes than those who underwent the thoracic approach.
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Affiliation(s)
- Hiroyuki Kitagawa
- Department of Surgery, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan.
| | - Jun Iwabu
- Department of Surgery, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Kazune Fujisawa
- Department of Surgery, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Michiya Kobayashi
- Department of Human Health and Medical Sciences, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
| | - Kazuhiro Hanazaki
- Department of Surgery, Kochi Medical School, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
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Hayasaka K, Ishida H, Kimura R, Nishimaki T. Spatial relationships of the bronchial arteries to the left recurrent laryngeal nerve in the sub-aortic arch area. Surg Today 2017; 48:346-351. [PMID: 28948403 DOI: 10.1007/s00595-017-1593-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/12/2017] [Indexed: 01/30/2023]
Abstract
PURPOSE To safely perform lymphadenectomy in the sub-aortic arch area during esophagectomy for esophageal cancer, we investigated the spatial relationships between the bronchial arteries (BAs) and the left recurrent laryngeal nerve (LRLN). METHODS For this macro-anatomical study, 72 cadavers were used. RESULTS Of the 195 dissected BAs, 15 (7.7%) arteries ran dorsally across the LRLN. Such a running pattern of the BA was found in 15 (20.8%) of the 72 cadavers. Fourteen (93.3%) of the 15 arteries ran anteriorly along the left side of the esophagus, and 13 (86.7%) passed further to the lateral side of the left main bronchus to reach the ventral surface of the tracheobronchus; we named this running pattern "Type III". Of the 51 arteries with the Type III pattern, 25.5% ran across the dorsal side of the LRLN. CONCLUSION Approximately 20% of the cadavers had BAs running dorsally to the LRLN in the sub-aortic arch area. Most of these arteries had the Type III pattern. One-quarter of the BAs with the Type III pattern showed this running pattern. Care must be practiced to safely perform lymphadenectomy for esophageal cancer in patients with Type III BAs.
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Affiliation(s)
- Ken Hayasaka
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan.
| | - Hajime Ishida
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan
| | - Ryosuke Kimura
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan
| | - Tadashi Nishimaki
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa, 903-0215, Japan
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Scholtemeijer MG, Seesing MFJ, Brenkman HJF, Janssen LM, van Hillegersberg R, Ruurda JP. Recurrent laryngeal nerve injury after esophagectomy for esophageal cancer: incidence, management, and impact on short- and long-term outcomes. J Thorac Dis 2017; 9:S868-S878. [PMID: 28815085 DOI: 10.21037/jtd.2017.06.92] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Martijn G Scholtemeijer
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten F J Seesing
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hylke J F Brenkman
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luuk M Janssen
- Department of Head and Neck Surgical Oncology, Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Makino H, Yoshida H, Maruyama H, Yokoyama T, Hirakata A, Ueda J, Takada H, Matsutani T, Nomura T, Hagiwara N, Uchida E. An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus. J Vis Surg 2016; 2:166. [PMID: 29078551 DOI: 10.21037/jovs.2016.11.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/13/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position. METHODS Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO2 insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus. RESULTS We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%. CONCLUSIONS Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.
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Affiliation(s)
- Hiroshi Makino
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Yoshida
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hiroshi Maruyama
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Tadashi Yokoyama
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Atsushi Hirakata
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Jyunji Ueda
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Hideyuki Takada
- Department of Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Tsutomu Nomura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Nobutoshi Hagiwara
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Eiji Uchida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
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Hikage M, Kamei T, Nakano T, Abe S, Katsura K, Taniyama Y, Sakurai T, Teshima J, Ito S, Niizuma N, Okamoto H, Fukutomi T, Yamada M, Maruyama S, Ohuchi N. Impact of routine recurrent laryngeal nerve monitoring in prone esophagectomy with mediastinal lymph node dissection. Surg Endosc 2016; 31:2986-2996. [PMID: 27826777 DOI: 10.1007/s00464-016-5317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/25/2016] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Makoto Hikage
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Takashi Kamei
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Toru Nakano
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeo Abe
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kazunori Katsura
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yusuke Taniyama
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Tadashi Sakurai
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Jin Teshima
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Soichi Ito
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Nobuchika Niizuma
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Toshiaki Fukutomi
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masato Yamada
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shota Maruyama
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Noriaki Ohuchi
- Department of Surgical Oncology, Graduate School of Medicine, Tohoku University, Sendai, Japan
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Yu S, Lin J, Chen C, Lin J, Han Z, Lin W, Kang M. Recurrent laryngeal nerve lymph node dissection may not be suitable for all early stage esophageal squamous cell carcinoma patients: an 8-year experience. J Thorac Dis 2016; 8:2803-2812. [PMID: 27867556 DOI: 10.21037/jtd.2016.10.34] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) injury is one of the most frequent postoperative complications of esophageal squamous cell carcinoma (ESCC) radical resection. This study aims to develop a novel scoring system to predict recurrent laryngeal nerve lymph node (RLNLN) metastases in early ESCC and explore the indications for precise RLN lymphadenectomy. METHODS Early stage ESCC patients from 2006 to 2014 were analyzed. Patient and pathologic characteristics were compared between patients with RLNLN metastases and those without. Univariate and multivariate analyses were performed to establish a scoring system that estimates the risks of RLNLN metastases. The indications for RLNLN dissection were validated by survival rate, postoperative complications, and metastases rate. RESULTS A total of 311 cases selected from 1,466 ESCC patients were divided into the dissection group and the control group. Age, tumor length, macroscopic tumor type, T stage, tumor location and tumor differentiation were independent predictors of RLNLN metastases. The weighted scoring system included age (+2 for <56 years), tumor length (+2 for over 4.45 cm), tumor location (+4 for upper thoracic, +2 for mid-thoracic) and macroscopic tumor type (+1 for advanced type). The total number of points estimated the probability of RLNLN metastases [low-risk (0-2 point), 0%; moderate-risk (3-4 points), 9.8%; and high-risk (>4 points), 43.4%]. Besides, the dissection group had more complications and similar survival rate when compared with the control group. CONCLUSIONS We developed a novel scoring system that accurately estimated the risk of RLNLN metastases in early ESCC patients. RLN lymphadenectomy may be safely omitted for the patients in the low-risk subgroup.
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Affiliation(s)
- Shaobin Yu
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Jihong Lin
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Chenshu Chen
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Jiangbo Lin
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Ziyang Han
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Wenwei Lin
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Mingqiang Kang
- The Second Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou 350001, China
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Noshiro H, Kai K, Yoda Y, Kono H, Uchiyama A. Palsy of the recurrent laryngeal nerves in association with an ultrasonic activated device during thoracoscopic esophagectomy with three-field lymphadenectomy. Esophagus 2016. [DOI: 10.1007/s10388-016-0543-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
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43
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Successful esophageal carcinoma resection with intraoperative neuromonitoring in a patient with non-recurrent inferior laryngeal nerve. Esophagus 2016. [DOI: 10.1007/s10388-015-0493-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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44
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Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival. Gastroenterol Res Pract 2015; 2015:518281. [PMID: 26246803 PMCID: PMC4515501 DOI: 10.1155/2015/518281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/28/2015] [Accepted: 06/25/2015] [Indexed: 12/18/2022] Open
Abstract
Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.
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