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Fu S, Guo Y, Lu X, Song X, Qin W, Zheng L, Huang X, Xie M, Lu Y, Lai R. Effectiveness of recurrent laryngeal nerve monitoring on nerve paralysis during open McKeown esophagectomy: a prospective, cohort study. Langenbecks Arch Surg 2025; 410:158. [PMID: 40366454 DOI: 10.1007/s00423-025-03732-6] [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: 10/29/2024] [Accepted: 05/06/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND Recurrent laryngeal nerve paralysis (RLNP) is a critical postoperative complication in esophagectomy. Intraoperative nerve monitoring (IONM) is a technique that can be used in high-risk surgeries to prevent, identify, and mitigate nerve damage. In this prospective study, we evaluated the feasibility and effectiveness of IONM in open McKeown esophagectomy for esophageal cancer. METHODS From December 2020 to September 2023, 88 patients diagnosed with esophageal cancer were enrolled to receive IONM for open McKeown esophagectomy at Cancer Center, Sun Yat-sen University. The primary outcome was the incidence of RLNP after extubation. The secondary outcomes were postoperative complications, number of dissected lymph nodes, length of hospital stay, ICU duration and number of deaths. RESULTS A total of 83 patients were included in the final analysis. The incidence of RLNP after extubation was 30.1%. The occurrence of postoperative pulmonary complications was 20.5%. The median hospital stays were 13 days. The incidence of anastomotic leakage was 13.3%. No in-hospital deaths were reported. Postoperative RLNP prolonged the length of hospital stay (P = 0.042). CONCLUSION Our findings indicated that IONM could potentially be associated with a possible reduction in RLNP incidence following open McKeown esophagectomy for esophageal cancer. However, future research including well-designed randomized controlled trials may be beneficial to clarify these preliminary results. TRIAL REGISTRATION NUMBER ChiCTR2000029687 https://www.chictr.org.cn/showproj.html?proj=49103.
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Affiliation(s)
- Shuwen Fu
- Department of Anesthesiology, Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, 74 Zhongshan Rd 2, Guangzhou, China
| | - Ying Guo
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Xiaofan Lu
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Xiong Song
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Weiyi Qin
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Liquan Zheng
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Xiaofeng Huang
- Department of Anesthesiology, Gansu Provincial Cancer Hospital, Lanzhou, China
| | - Manxiu Xie
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Yali Lu
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China
| | - Renchun Lai
- Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Guangdong Esophageal Cancer Institute, Sun Yat-Sen University Cancer Center, Guangzhou, 510060, China.
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Furube T, Takeuchi M, Kawakubo H, Noma K, Maeda N, Daiko H, Ishiyama K, Otsuka K, Sato Y, Koyanagi K, Tajima K, Garcia RN, Maeda Y, Matsuda S, Kitagawa Y. Usefulness of an Artificial Intelligence Model in Recognizing Recurrent Laryngeal Nerves During Robot-Assisted Minimally Invasive Esophagectomy. Ann Surg Oncol 2024; 31:9344-9351. [PMID: 39266790 DOI: 10.1245/s10434-024-16157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 08/23/2024] [Indexed: 09/14/2024]
Abstract
BACKGROUND Recurrent laryngeal nerve (RLN) palsy is a common complication in esophagectomy and its main risk factor is reportedly intraoperative procedure associated with surgeons' experience. We aimed to improve surgeons' recognition of the RLN during robot-assisted minimally invasive esophagectomy (RAMIE) by developing an artificial intelligence (AI) model. METHODS We used 120 RAMIE videos from four institutions to develop an AI model and eight other surgical videos from another institution for AI model evaluation. AI performance was measured using the Intersection over Union (IoU). Furthermore, to verify the AI's clinical validity, we conducted the two experiments on the early identification of RLN and recognition of its location by eight trainee surgeons with or without AI. RESULTS The IoUs for AI recognition of the right and left RLNs were 0.40 ± 0.26 and 0.34 ± 0.27, respectively. The recognition of the right RLN presence in the beginning of right RLN lymph node dissection (LND) by surgeons with AI (81.3%) was significantly more accurate (p = 0.004) than that by surgeons without AI (46.9%). The IoU of right RLN during right RLN LND recognized by surgeons with AI (0.59 ± 0.18) was significantly higher (p = 0.010) than that by surgeons without AI (0.40 ± 0.29). CONCLUSIONS Surgeons' recognition of anatomical structures in RAMIE was improved by our AI system with high accuracy. Especially in right RLN LND, surgeons could recognize the RLN more quickly and accurately by using the AI model.
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Affiliation(s)
- Tasuku Furube
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan.
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan.
| | - Kazuhiro Noma
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoaki Maeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital, Chuo City, Tokyo, Japan
| | - Koshiro Ishiyama
- Department of Esophageal Surgery, National Cancer Center Hospital, Chuo City, Tokyo, Japan
| | - Koji Otsuka
- Esophageal Cancer Center, Showa University Hospital, Shinagawa City, Tokyo, Japan
| | - Yoshihito Sato
- Esophageal Cancer Center, Showa University Hospital, Shinagawa City, Tokyo, Japan
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Rodrigo Nicida Garcia
- Department of Gastroenterology, Digestive Surgery Division, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Yusuke Maeda
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjuku City, Tokyo, Japan
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Liatsou E, Bellos I, Katsaros I, Michailidou S, Karela NR, Mantziari S, Rouvelas I, Schizas D. Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis. Dis Esophagus 2024; 37:doae063. [PMID: 39137391 DOI: 10.1093/dote/doae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/25/2024] [Accepted: 08/03/2024] [Indexed: 08/15/2024]
Abstract
The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.
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Affiliation(s)
- Efstathia Liatsou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Bellos
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Styliani Michailidou
- First Department of Paediatric Surgery, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Nina-Rafailia Karela
- Second Department of Internal Medicine, Elpis General Hospital of Athens, Athens, Greece
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Starkey A, Lincoln L, Fenton-Lee D, Christie LJ. An audit of perioperative speech pathology intervention on improving enhanced recovery after surgery in oesophagectomy patients. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-6. [PMID: 39223801 DOI: 10.1080/17549507.2024.2388066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
PURPOSE To evaluate the impact of a speech-language pathology (SLP) pathway on recovery following oesophagectomy. METHOD An audit was conducted at a single metropolitan public hospital in Sydney, Australia. Patients between 2014-2021 undergoing a three-stage oesophagectomy (n = 41) were included in the study. The sample was divided into two groups, those who received usual care (2014-2019) and those who received perioperative SLP assessment and intervention (2020-2021), with data collected across swallowing and health outcomes. Patient demographics and outcomes between the two groups were compared. RESULT Patients who received perioperative SLP intervention commenced oral intake faster postoperatively (SLP intervention group Mdn = 6.50 days, IQR = 6.00-7.00; usual care group Mdn = 9.00 days, IQR = 7.00-13.25; p = 0.001). There was no statistically significant difference between groups in rates of aspiration on the postoperative leak test (p = 0.32). No statistically significant differences were found between the two groups in length of hospital stay or number of swallowing-related medical images completed during their admission. CONCLUSION Perioperative SLP intervention has a positive impact on commencing oral intake following a three-stage oesophagectomy, however, it does not have a significant impact on rates of aspiration postoperatively. This pathway may contribute to enhanced recovery after oesophagectomy.
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Affiliation(s)
- Amelia Starkey
- Speech Pathology Department, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Laura Lincoln
- Speech Pathology Department, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Douglas Fenton-Lee
- Upper Gastrointestinal and General Surgery, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Lauren J Christie
- Allied Health Research Unit, St Vincent's Health Network Sydney, Darlinghurst, Australia
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, North Sydney, Australia
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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; 176:713-720. [PMID: 38890101 DOI: 10.1016/j.surg.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Ye G, Pan G, Zhu X, Li N, Liu H, Geng G, Jiang J. Metastatic patterns of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma without neoadjuvant therapy. J Cancer Res Clin Oncol 2024; 150:387. [PMID: 39110234 PMCID: PMC11306275 DOI: 10.1007/s00432-024-05911-2] [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: 06/08/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024]
Abstract
PURPOSE This research aimed to clarify the metastatic patterns of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma and to investigate appropriate strategies for lymph node dissection. METHODS Patients with thoracic esophageal squamous cell carcinoma receiving esophagectomy from December 2020 to April 2024 were retrospectively analyzed. Risk factors for subcarinal, right and left recurrent laryngeal nerve lymph nodes metastasis were determined by chi-square test and multivariate logistic regression analysis. We visualized the metastasis rates of these specific lymph nodes based on the different clinicopathological characteristics. Correlation between subcarinal, right and left recurrent laryngeal lymph nodes metastasis and postoperative complications were also analyzed. RESULTS A total of 503 thoracic esophageal squamous carcinoma patients who underwent esophagectomy were enrolled. The metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes were 10.3%, 10.3%, and 10.9%, respectively. The lymphovascular invasion status and tumor location were the significant predictors for subcarinal and right recurrent laryngeal nerve lymph nodes metastasis, respectively (P < 0.001 and P = 0.013). For left recurrent laryngeal nerve lymph node metastasis, younger age (P = 0.020) and presence of lymphovascular invasion (P = 0.009) were significant risk factors. Additionally, pulmonary infection is the most frequent postoperative complication in patients with dissection of subcarinal, right and left recurrent laryngeal lymph nodes. There was no significant difference in the incidence of anastomotic leakage (P = 0.872), pulmonary infection (P = 0.139), chylothorax (P = 0.702), and hoarseness (P = 0.179) between the subcarinal lymph node dissection cohort and the reservation cohort. The incidence of hoarseness significantly increased in both right (P = 0.042) and left (P = 0.010) recurrent laryngeal nerve lymph nodes dissection cohorts compared by the reservation cohorts, with incidence rates of 5.9% and 6.7%, respectively. CONCLUSIONS The metastasis rates of subcarinal, right and left recurrent laryngeal nerve lymph nodes in thoracic esophageal squamous cell carcinoma were all over 10%. The dissection of subcarinal lymph nodes does not increase postoperative complications risk, while recurrent laryngeal nerve lymph nodes dissection significantly increases the incidence of hoarseness. Thus, lymph node dissection of subcarinal lymph nodes should be conducted routinely, while recurrent laryngeal nerve lymph nodes dissection may be selectively performed in specific patients.
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Affiliation(s)
- Guanzhi Ye
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China
| | - Gaojian Pan
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China
| | - Xiaolei Zhu
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China
| | - Ning Li
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China
| | - Hongming Liu
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China
| | - Guojun Geng
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China.
| | - Jie Jiang
- Department of Thoracic Surgery, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, No 55, Zhenhai Road, Xiamen, Fujian, 361003, China.
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Kaneko T, Kato T, Shiko Y, Kawasaki Y, Koyama K. Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study. J Anesth 2024; 38:347-353. [PMID: 38430260 PMCID: PMC11096227 DOI: 10.1007/s00540-024-03315-7] [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: 05/09/2023] [Accepted: 02/01/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. METHODS The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. RESULTS The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. CONCLUSION These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.
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Affiliation(s)
- Tomomi Kaneko
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-city, Saitama, 350-8550, Japan.
| | - Takao Kato
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-city, Saitama, 350-8550, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Faculty of Nursing, Japanese Red Cross College of Nursing, Tokyo, Japan
| | - Kaoru Koyama
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-city, Saitama, 350-8550, Japan
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Kuo CT, Chao YK. ASO Author Reflections: Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study. Ann Surg Oncol 2024; 31:2513-2514. [PMID: 38158495 DOI: 10.1245/s10434-023-14828-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Chun-Ting Kuo
- Division of Thoracic 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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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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Lechien JR, Hans S, Mau T. Management of Bilateral Vocal Fold Paralysis: A Systematic Review. Otolaryngol Head Neck Surg 2024; 170:724-735. [PMID: 38123531 DOI: 10.1002/ohn.616] [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: 06/22/2023] [Revised: 10/31/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To review the current literature about epidemiology, etiologies and surgical management of bilateral vocal fold paralysis (BVFP). DATA SOURCES PubMED, Scopus, and Cochrane Library. REVIEW METHODS A systematic review of the literature on epidemiology, etiologies, and management of adult patients with BVFP was conducted through preferred reporting items for systematic reviews and meta-analyses statements by 2 investigators. RESULTS Of the 360 identified papers, 245 were screened, and of these 55 were considered for review. The majority (76.6%) of BVFP cases are iatrogenic. BVFP requires immediate tracheotomy in 36.2% of cases. Laterofixation of the vocal fold was described in 9 studies and is a cost-effective alternative procedure to tracheotomy while awaiting potential recovery. Unilateral and bilateral posterior transverse cordotomy outcomes were reported in 9 and 7 studies, respectively. Both approaches are associated with a 95.1% decannulation rate, adequate airway volume, but voice quality worsening. Unilateral/bilateral partial arytenoidectomy data were described in 4 studies, which reported lower decannulation rate (83%) and better voice quality outcome than cordotomy. Revision rates and complications vary across studies, with complications mainly involving edema, granuloma, fibrosis, and scarring. Selective posterior cricoarytenoid reinnervation is being performed by more surgeons and should be a promising addition to the BVFP surgical armamentarium. CONCLUSION Depending on techniques, the management of BVFP may be associated with several degrees of airway improvements while worsened or unchanged voice quality. The heterogeneity between studies, the lack of large-cohort controlled randomized studies and the confusion with posterior glottic stenosis limit the draw of clear conclusion about the superiority of some techniques over others.
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Affiliation(s)
- Jérôme R Lechien
- Department of Otolaryngology, Elsan Hospital, Paris, France
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France
- Division of Laryngology and Bronchoesophagology, Department of Otolaryngology Head Neck Surgery, EpiCURA Hospital, UMONS Research Institute for Health Sciences and Technology, Faculty of Medicine, University of Mons (UMons), Mons, Belgium
- Department of Otolaryngology-Head & Neck Surgery, CHU Saint-Pierre (CHU de Bruxelles), Brussels, Belgium
| | - Stéphane Hans
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), Paris, France
| | - Ted Mau
- Department of Otolaryngology-Head and Neck Surgery, Clinical Center for Voice Care, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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11
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Farrow H, Pickering OJ, Gossage JA, Pucher PH. Impact of thoracic duct resection during radical esophagectomy on oncological and survival outcomes: Systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107271. [PMID: 37979459 DOI: 10.1016/j.ejso.2023.107271] [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: 08/06/2023] [Revised: 10/14/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023]
Abstract
Practice is variable in the inclusion or exclusion of the thoracic duct (TD) as part of the resected specimen and associated lymphadenectomy in radical esophagectomy for esophageal cancer. While some surgeons believe that the removal of TD-associated nodes may improve radicality and survival, others suggest this represents systemic disease and resection may increase morbidity without survival benefit. A systematic review was performed up to March 2023 using the search terms 'esoph∗' AND 'thoracic duct' for relevant articles which compared thoracic duct preservation (TDP) to resection (TDR) in esophagectomy for esophageal cancer. Included studies were required to report relevant oncological outcomes including at least one of overall survival (OS), disease free survival (DFS) and nodal yield. Seven cohort studies were included in data synthesis, including data for 5926 patients. None of the reported studies were randomised controlled trials. All studies originated from Japan or South Korea with almost exclusively squamous cell-type cancer. Nodal yield was higher in TDR groups. TDR was equivalent or inferior to TDP with reference to clinical outcomes (length of stay, morbidity, mortality). A single study reported increased OS in the TDR group while the remaining studies reported no significant difference. Overall study quality was moderate to poor. While an increased nodal yield may be associated with TDR, this may also be associated with higher morbidity, and currently available data does not suggest any survival benefit.
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Affiliation(s)
- Harry Farrow
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James A Gossage
- Department of Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK; Division of Surgery, Imperial College London, London, UK; Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK.
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12
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Liu D, Wu S, Ni J, Xiang J, Zhang J. Postoperative Radiotherapy in Curatively Resected Esophageal Squamous Cell Carcinoma With Occult Recurrent Laryngeal Nerve Lymph Node Metastasis. Cancer Control 2024; 31:10732748241285142. [PMID: 39259654 PMCID: PMC11406587 DOI: 10.1177/10732748241285142] [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] [Indexed: 09/13/2024] Open
Abstract
OBJECTIVES Surgery is the mainstream treatment for early-stage esophageal squamous cell carcinoma (ESCC) and occult recurrent laryngeal nerve lymph node metastasis (RLNM) is not uncommon among those with R0 resection. The clinical value of postoperative radiotherapy (PORT) in patients with RLNM only is still controversial. METHODS Consecutive patients with early-stage ESCC treated with R0 resection and pathologically confirmed RLNM only from June 2012 to July 2022 were retrospectively reviewed. PORT, covering the supraclavicular and superior mediastinum area (small T-field) at a dose of 50.4 Gy for 28 fractions, was performed in some patients. Propensity score matching (PSM) was performed to balance the baseline characteristics between patients with or without PORT. Pattern of failure, disease-free survival (DFS), and overall survival (OS) were compared. RESULTS Among the 189 patients identified, 69 (35.5%) received PORT and the other 120 (63.5%) did not. After PSM, 154 patients were included in the matched cohort, including 62 in the PORT group and 92 in the non-PORT group. With a median follow-up of 48 (95% CI: 40.3-55.7) months, 69 patients developed their initial disease recurrence in the whole population and PORT significantly decreased the frequency of local recurrence (61.2% vs 21.4%) among those with recurrent disease. Additionally, in the PSM matched cohort, PORT significantly prolonged patients' DFS (HR 0.393, P = 0.002) and OS (HR 0.462, P = 0.020). Moreover, PORT remained as the independent factor associated with improved DFS (HR 0.360, P = 0.001) and OS (HR 0.451, P = 0.021) after multivariate Cox analyses. In addition, tumor location and pathological TNM stage were found to be independent prognostic factors associated with survival outcomes. CONCLUSION PORT is associated with improved DFS and OS in ESCC patients with R0 resection and RLNM only, which warrants future validation.
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Affiliation(s)
- Di Liu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, People's Republic of China
| | - Songsong Wu
- Department of Radiation Oncology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jianjiao Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, People's Republic of China
| | - Jiaqing Xiang
- Department of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Institute of Thoracic Oncology, Fudan University, Shanghai, People's Republic of China
| | - Junhua Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, People's Republic of China
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13
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Dongming G, Yuequan J, Qi Z, Huajie X, Zhiqiang W. A novel technique for lymphadenectomy along the left recurrent laryngeal nerve during minimally invasive esophagectomy: a retrospective cohort study. BMC Surg 2023; 23:355. [PMID: 37990240 PMCID: PMC10662753 DOI: 10.1186/s12893-023-02263-5] [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: 08/21/2023] [Accepted: 11/09/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND In the context of esophageal cancers, lymph nodes located along the left recurrent laryngeal nerve (RLN) exhibit significant involvement, posing significant challenges for lymphadenectomy. The objective of this study is to assess the safety and efficacy of a novel technique for lymphadenectomy called "elastic suspension of left RLN" method, comparing it with the conventional approach. METHODS Between January 2016 and June 2020, a total of 393 patients who underwent minimally invasive esophagectomy with gastroplasty and cervical esophagogastric anastomosis were enrolled in the study. Among them, 291 patients underwent the "elastic suspension of left RLN" method, while 102 patients underwent the conventional method. We compared the number of harvested lymph nodes along the left RLN and assessed postoperative complications between these two groups. Additionally, the overall survival (OS) rate was calculated and analyzed for the entire cohort. RESULTS In comparison to the conventional group, the elastic suspension group exhibited a higher yield of harvested lymph nodes along the left RLN (5.36 vs 3.07, P < 0.001). Moreover, the incidence of postoperative hoarseness was lower in the elastic suspension group (10.65% vs 18.63%, P = 0.038). The average duration of lymphadenectomy along the left RLN was 11.85 min in the elastic suspension group and 11.51 min in the conventional group, although this difference was not statistically significant (P = 0.091). Notably, the overall 5-year OS was markedly higher in the elastic suspension group compared to the conventional group (64.1% vs. 50.1%, P = 0.020). CONCLUSIONS The findings suggest that the novel "elastic suspension of left RLN" method for lymphadenectomy along the left RLN in minimally invasive esophagectomy is both safe and effective. This technique holds promise for widespread adoption in esophagectomy procedures.
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Affiliation(s)
- Guo Dongming
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Jiang Yuequan
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Zhang Qi
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Xing Huajie
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Wang Zhiqiang
- Department of Thoracic Cancer Center, Chongqing University Cancer Hospital, Chongqing, 400030, China.
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Fung MMH, Wong IYH, Chan FSY, Law TT, Chan KK, Wong CLY, Law SYK, Lang BHH. A Prospective Study Evaluating the Feasibility and Accuracy of Post-operative Laryngeal Ultrasonography (LUSG) in Assessment of Vocal Cord Function After Esophagectomy. World J Surg 2023; 47:2792-2799. [PMID: 37540267 DOI: 10.1007/s00268-023-07128-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Vocal cord paresis (VCP) is a serious complication after esophagectomy. Conventional diagnosis of VCP relies on flexible laryngoscopy (FL), which is invasive. Laryngeal ultrasonography (LUSG) is non-invasive and convenient. It has provided accurate VC evaluation after thyroidectomy but it is unclear if it is just as accurate following esophagectomy. This prospective study evaluated the feasibility and accuracy of LUSG in VC assessment on day-1 after esophagectomy. METHODS Consecutive patients from a tertiary teaching hospital who underwent elective esophagectomy were prospectively recruited. All received pre-operative FL, and post-operative LUSG and FL on Day-1, each performed by a blinded, independent assessor. The primary outcomes were feasibility and accuracy of LUSG in the diagnosis of VCP on Day-1 post-esophagectomy. The accuracy of voice assessment (VA) was analyzed. RESULTS Twenty-six patients were eligible for analysis. The median age was 70 years (66-73). Majority were male (84.6%). Twenty-five (96.2%) received three-phase esophagectomy. Twenty-four (96%) had same-stage anastomosis at the neck. Three (11.5%) developed temporary and one (3.8%) developed permanent unilateral VCP. Overall VC visualization rate by LUSG was 100%; sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of LUSG were 75.0%, 100%, 100%, 98.0%, 98.1% respectively, and superior to VA. Combining LUSG with VA findings could pick up all VCPs i.e. improved sensitivity and NPV to 100%. CONCLUSION LUSG is a highly feasible, accurate and non-invasive method to evaluate VC function early after esophagectomy. Post-operative FL may be avoided in patients with both normal LUSG and voice.
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Affiliation(s)
- Matrix Man-Him Fung
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ian Yu-Hong Wong
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Fion Siu-Yin Chan
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Tsz-Ting Law
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Kwan-Kit Chan
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Claudia Lai-Yin Wong
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Simon Ying-Kit Law
- Division of Esophageal and Upper Gastro-Intestinal Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
| | - Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.
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15
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Feng J, Wang L, Yang X, Chen Q, Cheng X. A novel immune-nutritional score predicts response to neoadjuvant immunochemotherapy after minimally invasive esophagectomy for esophageal squamous cell carcinoma. Front Immunol 2023; 14:1217967. [PMID: 37954582 PMCID: PMC10634314 DOI: 10.3389/fimmu.2023.1217967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Background The role of neoadjuvant immunochemotherapy (NICT) has gradually attracted attention in recent years. To date, sensitive and reliable blood indicators to forecast the therapeutic response are still lacking. This study aimed to conduct a novel predictive score based on a variety of peripheral hematological immune-nutritional indicators to predict the therapeutic response in esophageal squamous cell carcinoma (ESCC) receiving NICT. Methods There were 206 ESCC patients receiving NICT retrospectively recruited. With pathological complete response (pCR) as the dependent variable, independent risk variables of various peripheral blood immune-nutritional indexes were screened by logistic regression analyses to establish an integrative score. Results By logical regression analyses, lymphocyte to monocyte ratio (LMR) and body mass index (BMI) were independent risk factors among all immune-nutritional indices. Then, an integrative score named BMI-LMR score (BLS) was established. Compared with BMI or LMR, BLS was related to complications, especially for respiratory complication (P=0.012) and vocal cord paralysis (P=0.021). Among all patients, 61 patients (29.6%) achieved pCR after NICT. BLS was significantly related to pCR [odds ratio (OR)=0.269, P<0.001)]. Patients in high BLS cohort demonstrated higher 3-year overall survival (OS) (89.9% vs. 67.9%, P=0.001) and disease-free survival (DFS) (81.2% vs. 62.1%, P=0.001). BLS served as an independent factor of DFS [hazard ratio (HR) =2.044, P =0.020) and OS (HR =2.960, P =0.019). Conclusion The BLS, based on immune-nutritional indicators of BMI and LMR, employed as a straightforward, accurate, and useful indicator of pCR and prognostic prediction in ESCC patients undergoing NICT.
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Affiliation(s)
- Jifeng Feng
- Department of Thoracic Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
- Zhejiang Provincial Research Center for Upper Gastrointestinal Tract Cancer, Zhejiang Cancer Hospital, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Liang Wang
- Department of Thoracic Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Xun Yang
- Department of Thoracic Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Qixun Chen
- Department of Thoracic Oncological Surgery, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, Hangzhou, China
- Key Laboratory Diagnosis and Treatment Technology on Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Xiangdong Cheng
- Zhejiang Provincial Research Center for Upper Gastrointestinal Tract Cancer, Zhejiang Cancer Hospital, Hangzhou, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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16
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Gopinath SK, Jiwnani S, Valiyuthan P, Parab S, Niyogi D, Tiwari V, Pramesh CS. Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility. J Chest Surg 2023; 56:336-345. [PMID: 37574880 PMCID: PMC10480398 DOI: 10.5090/jcs.23.052] [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: 04/28/2023] [Revised: 06/25/2023] [Accepted: 07/06/2023] [Indexed: 08/15/2023] Open
Abstract
Background The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy. Methods This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups. Results Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy. Conclusion The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.
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Affiliation(s)
- Srinivas Kodaganur Gopinath
- Thoracic Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sabita Jiwnani
- Thoracic Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Parthiban Valiyuthan
- Department of Neurophysiology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Swapnil Parab
- Department of Anesthesiology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Devayani Niyogi
- Thoracic Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Virendrakumar Tiwari
- Thoracic Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - C. S. Pramesh
- Thoracic Surgical Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Komatsu S, Konishi T, Matsubara D, Soga K, Shimomura K, Ikeda J, Taniguchi F, Fujiwara H, Shioaki Y, Otsuji E. Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2022; 26:2444-2450. [PMID: 36221021 DOI: 10.1007/s11605-022-05472-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/03/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue. METHODS This study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated. RESULTS The overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05-0.98) was an independent factor avoiding postoperative RLN palsy. CONCLUSION The CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.
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Affiliation(s)
- Shuhei Komatsu
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan. .,Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Tomoki Konishi
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Daiki Matsubara
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Koji Soga
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Katsumi Shimomura
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Jun Ikeda
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Fumihiro Taniguchi
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yasuhiro Shioaki
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
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18
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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: 6] [Impact Index Per Article: 2.0] [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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19
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Impact of prior thoracoscopic experience on the learning curve of robotic McKeown esophagectomy: a multidimensional analysis. Surg Endosc 2022; 36:5635-5643. [PMID: 35075527 DOI: 10.1007/s00464-022-09050-y] [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: 03/15/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Left upper mediastinal lymph node dissection (UMLND)-a technically demanding step of McKeown esophagectomy-is frequently complicated by recurrent laryngeal nerve (RLN) palsy. Under the hypothesis that robotic esophagectomy (RE) could increase the safety and feasibility of UMLND, we retrospectively investigated the degree to which a pre-existing experience in video-assisted thoracoscopic esophagectomy (VATE) may affect the learning curves of this critical part of RE. METHODS Surgeon A had previously performed > 150 VATE procedures before transitioning to RE. While surgeon B had previously assisted to 50 RE, his pre-existing VATE experience consisted of less than five procedures. A total of 103 and 76 McKeown RE procedures were performed by surgeons A and B, respectively. The learning curve of left UMLND for each surgeon was examined using the cumulative sum method. RESULTS The inflection point of RLN palsy for surgeon A occurred at patient 31. While the nerve palsy rate decreased from 32.3 to 4.2% (p < 0.001), the number of nodes harvested during left UMLND did not appreciably change. Surgeon B showed a bimodal learning curve for RLN palsy with primary and secondary inflection points at patients 15 and 49, respectively. The RLN palsy rate initially decreased from 66.7% (patients 1-15) to 14.7% (patients 16-49), followed by an additional decline to 3.7% (patients 50-76). However, the number of nodes harvested during left UMLND showed a downtrend which was paralleled by decreasing rates of RLN palsy. These results indicate that surgeon B has not yet reached an ideal balance between an extensive UMLND and nerve protection. CONCLUSION The pre-existing VATE experience seems to affect the learning curves of left UMLND during RE.
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Wong IYH, Zhang RQ, Tsang RKY, Kwok JYY, Wong CLY, Chan DKK, Chan FSY, Law SYK. Improving Outcome of Superior Mediastinal Lymph Node Dissection During Esophagectomy: A Novel Approach Combining Continuous and Intermittent Recurrent Laryngeal Nerve Monitoring. Ann Surg 2021; 274:736-742. [PMID: 34310354 DOI: 10.1097/sla.0000000000005096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed at demonstrating the effects and learning curve of utilizing combined intermittent and continuous recurrent laryngeal nerve (RLN) monitoring for lymphadenectomy during esophagectomy. BACKGROUND RLN lymphadenectomy is oncologically important but is technically demanding. Vocal cord (VC) palsy as a result from RLN injury, carries significant morbidities. METHODS This is a retrospective study of consecutive esophageal squamous cell carcinoma (ESCC) patients who underwent transthoracic esophagectomy from 2010 to 2020. Combined nerve monitoring (CNM) included: CNM which involved a periodic stimulating left vagal electrode and intermittent nerve monitoring which utilized a stimulating probe to identify the RLNs. The integrity of the RLNs was assessed both intermittently and continuously. This technique was introduced in 2014. Patients were divided into "before CNM" and "CNM" groups. The primary outcome was the difference in number of RLN lymph nodes harvested and VC palsy rate. Learning curves were demonstrated by cumulative sum (CUSUM) analysis. RESULTS Two hundred and fifty-five patients were included with 157 patients in "CNM" group. The mean number of RLN lymph nodes harvested was significantly higher (4.31 vs 0.45, P < 0.0001) for the "CNM" group. VC palsy rates were significantly lower (17.8% vs 32.7%, P = 0.007). There was an initial increase in VC palsy rate, peaked at around 46 cases. The increase in lymph nodes harvested above the mean plateaued at around 96 cases. CONCLUSIONS CNM helped improve bilateral RLN lymphadenectomy. Lymph node harvesting was increased with reduction of VC palsy after a learning curve.
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Affiliation(s)
- Ian Y H Wong
- Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
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21
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Laparoscopic versus laparotomic gastric pull-up following thoracoscopic esophagectomy: A propensity score-matched analysis. Asian J Surg 2021; 45:468-472. [PMID: 34364763 DOI: 10.1016/j.asjsur.2021.07.049] [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: 03/05/2021] [Revised: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Because of its capacity to reduce surgical trauma to the chest wall, thoracoscopic esophagectomy is considered paramount for decreasing the risk of pulmonary complications in the context of minimally invasive esophagectomy. Whether laparoscopy (LS) following thoracoscopic esophagectomy can further improve outcomes compared with open laparotomy (OL) is unknown. MATERIALS AND METHODS We retrospectively reviewed the clinical and imaging records of 428 patients who received McKeown esophagectomy with a thoracoscopic approach for cancer. Using propensity score matching based on eight parameters (age, sex, body mass index, Charlson comorbidity index, tumor location, type of preoperative therapy, reconstruction route, and occurrence/severity of postoperative vocal cord palsy), 60 pairs were identified and compared with regard to perioperative complications and overall survival (OS). RESULT Compared with OL, LS resulted in lower blood loss (mean: 171.21 versus 107.58 mL, respectively, p = 0.023) and a reduced incidence of pneumonia (13.3% versus 3.3%, respectively, p = 0.048), albeit at the expense of a longer operating time (mean: 399.37 versus 443.93 min, respectively, p = 0.003). Notably, lymph node yields and OS of patients who were treated with LS were similar to those observed in those who underwent OL. CONCLUSIONS Patients who receive LS after thoracoscopic esophagectomy experience lower blood loss and have a reduced risk of pneumonia than those treated with OL.
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22
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Outcomes of Esophageal Cancer after Esophagectomy in the Era of Early Injection Laryngoplasty. Diagnostics (Basel) 2021; 11:diagnostics11050914. [PMID: 34065599 PMCID: PMC8160664 DOI: 10.3390/diagnostics11050914] [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: 04/24/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: severe weight loss was reported to be related to unilateral vocal fold paralysis (UVFP) after esophagectomy and could thus impair survival. Concomitant radical lymph node dissection along the recurrent laryngeal nerve during esophageal cancer surgery is controversial, as it might induce UVFP. Early intervention for esophagectomy-related UVFP by administering intracordal injections of temporal agents has recently become popular. This study investigated the survival outcomes of esophagectomy for esophageal squamous cell carcinoma (ESCC) after the introduction of early injection laryngoplasty (EIL). (2) Methods: a retrospective review of patients with ESCC after curative-intent esophagectomy was conducted in a tertiary referral medical center. The necessity of EIL with hyaluronic acid was comprehensively discussed for all symptomatic UVFP patients. The survival outcomes and related risk factors of ESCC were evaluated. (3) Results: among the cohort of 358 consecutive patients who underwent esophagectomy for ESCC, 42 (11.7%) showed postsurgical UVFP. Twenty-nine of them received office-based EIL. After EIL, the glottal gap area, maximum phonation time and voice outcome survey showed significant improvement at one, three and six months measurements. The number of lymph nodes in the resected specimen was higher in those with UVFP than in those without UVFP (30.1 ± 15.7 vs. 24.6 ± 12.7, p = 0.011). The Kaplan-Meier overall survival was significantly better in patients who had UVFP (p = 0.014), received neck anastomosis (p = 0.004), underwent endoscopic resection (p < 0.001) and had early-stage cancer (p < 0.001). Multivariate Cox logistic regression analysis showed two independent predictors of OS, showing that the primary stage and anastomosis type are the two independent predictors of OS. (4) Conclusion: EIL is effective in improving UVFP-related symptoms, thus providing compensatory and palliative measures to ensure the patient's postsurgical quality of life. The emerging use of EIL might encourage cancer surgeons to radically dissect lymph nodes along the recurrent laryngeal nerve, thus changing the survival trend.
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Jeon YJ, Cho JH, Lee HK, Kim HK, Choi YS, Zo JI, Shim YM. Management of patients with bilateral recurrent laryngeal nerve paralysis following esophagectomy. Thorac Cancer 2021; 12:1851-1856. [PMID: 33955175 PMCID: PMC8201530 DOI: 10.1111/1759-7714.13940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background Recurrent laryngeal nerve paralysis (RLNP) is a common complication after esophagectomy which can cause severe pulmonary complications. However, bilateral RLNP has been rarely reported in esophagectomy patients. The objective of our study is to investigate the clinical significance of patients who had bilateral RLNP following esophagectomy. Methods We retrospectively reviewed patients who underwent esophagectomy at a single center from 1994 to 2018. Among these, patients with bilateral vocal cord paralysis were included in this study. Results A total of 3217 patients were reviewed and 400 (12.4%) patients had RLNP, including 56 patients with bilateral RLNP identified by laryngoscopic examination. During the postoperative managements, 10 of the 56 patients (17.9%) required tracheostomy. Among them, two died of acute respiratory distress syndrome and the other eight patients were discharged after removing the tracheostomy tube. The median lengths of hospital and intensive care unit stay were 19.5 (range 8–157) and 2 (range 1–46) days, respectively. Forty‐six patients (83.6%) were discharged with oral feeding after swallowing therapy including tongue holding maneuver and head tilt exercise. The other five patients (8.9%) were discharged with alternative enteral feeding via jejunostomy, but they were able to achieve oral diet 2–3 months after surgery. Conclusion Bilateral RLNP following esophagectomy was rare, but it required great attention to prevent severe respiratory complications. However, only a few patients required tracheostomy and the majority achieved oral ingestion after intensive rehabilitation. Feeding education and respiratory rehabilitation are critical during the management of patients with bilateral RLNP.
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Affiliation(s)
- Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Kyu Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gyeonggi-do, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Ohi M, Toiyama Y, Yasuda H, Ichikawa T, Imaoka H, Okugawa Y, Fujikawa H, Okita Y, Yokoe T, Hiro J, Kusunoki M. Preoperative computed tomography predicts the risk of recurrent laryngeal nerve paralysis in patients with esophageal cancer undergoing thoracoscopic esophagectomy in the prone position. Esophagus 2021; 18:228-238. [PMID: 32743739 DOI: 10.1007/s10388-020-00767-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recurrent laryngeal nerve paralysis (RLNP) after thoracoscopic esophagectomy for esophageal cancer (EC) is known to be a major complication leading to poor quality of life. RLNP is mainly associated with surgical procedures performed near the RLN. Therefore, with focus on the region of the RLN, we used preoperative computed tomography to investigate the risk factors of RLNP in patients with EC undergoing thoracoscopic esophagectomy. METHODS We retrospectively examined 77 EC patients who underwent thoracoscopic esophagectomy in the prone position at our department between January 2010 and December 2018. Bilateral cross-sectional areas (mm2) of the fatty tissue around the RLN at the level of the lower pole of the thyroid gland were measured on preoperative axial computed tomography (CT) images. Univariate and multivariate logistic regression analysis was used to evaluate the association between the incidence of RLNP and patient clinical factors, including the cross-sectional areas. RESULTS RLNP occurred in 24 of 77 patients (31.2%). The incidence of RLNP was significantly more frequent on the left side than on the right. (26% vs. 5.2%, respectively). Univariate analysis identified the following left RLNP risk factors: intrathoracic operative time (> 235 min), and area around the RLN (> 174.3 mm2). Multivariate analysis found that the area around the RLN was an independent risk factor of left RLNP. CONCLUSION An increased area around the RLN measured on an axial CT view at the level of the lower pole of the thyroid gland was a risk factor of RLNP in EC patients undergoing thoracoscopic esophagectomy in the prone position.
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Affiliation(s)
- Masaki Ohi
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.
| | - Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Hiromi Yasuda
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Takashi Ichikawa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Hiroki Imaoka
- Department of Innovative Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Yoshinaga Okugawa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Fujikawa
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Takeshi Yokoe
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Junichiro Hiro
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan.,Department of Innovative Surgery, Mie University Graduate School of Medicine, Edobashi 2-174, Tsu, Mie, 514-8507, Japan
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25
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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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26
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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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27
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Li XK, Xu Y, Zhou H, Cong ZZ, Wu WJ, Qiang Y, Shen Y. Does robot-assisted minimally invasive oesophagectomy have superiority over thoraco-laparoscopic minimally invasive oesophagectomy in lymph node dissection? Dis Esophagus 2021; 34:5862145. [PMID: 32582945 DOI: 10.1093/dote/doaa050] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/20/2020] [Accepted: 05/15/2020] [Indexed: 12/24/2022]
Abstract
Although robotic techniques have been used for oesophagectomy for many years, whether robot-assisted minimally invasive oesophagectomy (RAMIE) can actually improve outcomes and surpass thoraco-laparoscopic minimally invasive oesophagectomy (MIE) in the success rate of lymph node dissection remains to be empirically demonstrated. Therefore, we performed this systematic review and meta-analysis of case-control studies to systematically compare the effect of lymph node dissection and the incidence of vocal cord palsy between RAMIE and MIE. The PubMed, EMBASE, and Web of Science databases were systematically searched up to December 1, 2019, for case-control studies that compared RAMIE with MIE. Thirteen articles were included, with a total of 1,749 patients with esophageal cancer, including 866 patients in the RAMIE group and 883 patients in the MIE group. RAMIE yielded significantly larger numbers of total dissected lymph nodes (WMD = 1.985; 95% CI, 0.448-3.523; P = 0.011) and abdominal lymph nodes (WMD = 1.686; 95% CI, 0.420-2.951; P = 0.009) as well as lymph nodes along RLN (WMD = 0.729; 95% CI, 0.348-1.109; P < 0.001) than MIE. Additionally, RAMIE could significantly decrease estimated blood loss (WMD = -11.208; 95% CI, -19.358 to -3.058; P = 0.007) and the incidence of vocal cord palsy (OR = 0.624; 95% CI, 0.411-0.947; P = 0.027) compared to MIE. Compared with MIE, RAMIE resulted in a higher total lymph node yield and a higher lymph node yield in the abdomen and along RLN, along with reduced blood loss during surgery and the incidence of vocal cord palsy. Therefore, RAMIE could be considered to be a standard treatment, with less blood loss, lower incidence of vocal cord palsy, and more radical lymph node dissection, exhibiting superiority over MIE.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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28
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Zheng C, Li XK, Zhang C, Zhou H, Ji SG, Zhong JH, Xu Y, Cong ZZ, Wang GM, Wu WJ, Shen Y. Comparison of short-term clinical outcomes between robot-assisted minimally invasive esophagectomy and video-assisted minimally invasive esophagectomy: a systematic review and meta-analysis. J Thorac Dis 2021; 13:708-719. [PMID: 33717543 PMCID: PMC7947517 DOI: 10.21037/jtd-20-2896] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Though robot-assisted minimally invasive esophagectomy (RAMIE) is demonstrated to offer a better visualization and provide a fine dissection of the mediastinal structures to facilitate the complex thoracoscopic operation, the superiorities of RAMIE over MIE have not been well verified. The aim of this study was to explore the actual superiorities through comparing short-term results of RAMIE with that of MIE. Methods PubMed, EMBASE and web of science databases were systematically searched up to September 1, 2020 for case-controlled studies that compared RAMIE with TLMIE. Results Fourteen studies were identified, with a total of 2,887 patients diagnosed with esophageal cancer, including 1,435 patients subjected to RAMIE group and 1,452 patients subjected to MIE group. The operative time in RAMIE was still significantly longer than that in MIE group (OR =0.785; 95% CI, 0.618-0.952; P<0.001). The incidence of pneumonia was significantly lower in RAMIE group compared with MIE group (OR =0.677; 95% CI, 0.468-0.979; P=0.038). Conclusions RAMIE has the superiorities over MIE in short-term outcomes in terms of pneumonia and vocal cord palsy. Therefore, RAMIE could be considered as a standard treatment for patients with esophageal cancer.
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Affiliation(s)
- Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Hai Zhou
- Department of Cardiothoracic Surgery, Nanjing Second Hospital, Medical School of Southeast University, Nanjing, China
| | - Sai-Guang Ji
- Department of Cardiothoracic Surgery, Nanjing Second Hospital, Medical School of Southeast University, Nanjing, China
| | - Ji-Hong Zhong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gao-Ming Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou School of Clinical Medicine of Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Second Hospital, Medical School of Southeast University, Nanjing, China
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Sasikumar K, Kalayarasan R, Gnanasekaran S, Chandrasekar S, Pottakkat B. Minimally invasive oesophagectomy with a total two-field lymphadenectomy after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of the oesophagus: A prospective study. J Minim Access Surg 2021; 17:49-55. [PMID: 31929228 PMCID: PMC7945645 DOI: 10.4103/jmas.jmas_242_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/04/2019] [Accepted: 11/25/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION In the era of neoadjuvant chemoradiotherapy (NACTRT), the safety and clinical significance of radical lymphadenectomy specifically lymphadenectomy along the recurrent laryngeal nerve (RLN) has been questioned. Furthermore, the compliance to NACTRT with the CROSS regimen has not been well studied in the Indian population. This prospective study aimed to determine the compliance with CROSS regimen, feasibility and short-term outcomes of minimally invasive oesophagectomy (MIE) with a total two-field lymphadenectomy after NACTRT. METHODS A prospective study (January 2014 to December 2018) of patients with locally advanced oesophageal squamous cell carcinoma (SCC) eligible for NACTRT (cT1-4a, N0-1, M0) with CROSS regimen followed by MIE with total two-field lymphadenectomy. The compliance rate, post-operative complications and the pathological response rate were assessed. RESULTS Of the 166 patients with locally advanced SCC, 76 (45.8%) were eligible for NACTRT and 34 completed NACTRT followed by MIE with a total two-field lymphadenectomy (study group). Twenty-nine (38.1%) patients did not complete NACTRT due to complications or poor compliance. Median (range) blood loss was 125 (50-450) ml and the median (range) operation time for the thoracoscopic phase was 205 (155-325) min. Total median (range) lymph node count and mediastinal lymph node counts were 20 (11-33) and 12, (8-21) respectively. Most common post-operative complications were pneumonia (n = 12, 35.3%) followed by RLN palsy (n = 10, 29.4%). Of the 22 patients who had a complete pathological response of the primary tumour, 7 (31.8%) patients had a node-positive disease. CONCLUSION NACTRT followed by MIE is feasible in patients with locally advanced SCC. The nodal disease is common even in patients with the complete pathological response of the primary tumour. The dropout rate with NACTRT using the CROSS regimen is high in the present study.
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Affiliation(s)
- Kuppusamy Sasikumar
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Sandip Chandrasekar
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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Herr MJ, Macy Cottrell J, Kahl M, Weiman DS. Comprehensive Comparison of Right and Left Recurrent Laryngeal Nerves in the Tracheoesophageal Groove. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 16:148-151. [PMID: 33331204 DOI: 10.1177/1556984520976583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE A left-sided cervical approach to esophageal mobilization is considered safer given the perceived oblique path and more lateral orientation of the right recurrent laryngeal nerve (RLN) in the tracheoesophageal groove. Given the risk of recurrent laryngeal nerve, the current study investigated if there are differences in right and left RLN location in the tracheoesophageal groove. METHODS Right and left RLNs were carefully exposed in human cadavers. Comparison of location was determined at tracheal rings 2, 4, and 6 using 3 parameters: depth of the RLN from the anterior margin of the tracheal ring, lateral distance of the RLN from the posterior margin of the tracheal ring, and distance of the RLN to the anterior midline trachea following the curvature of the trachea. Statistical analysis was used to determine differences between the right and left sides. RESULTS Compared with the right RLN, the left RLN was slightly over 1 mm deeper at the second tracheal ring. Despite this trend, there was no significant difference in RLN location between individual sides or as an aggregate for any of the 3 parameters at tracheal rings 2, 4, or 6. CONCLUSIONS Careful characterization of RLN location precludes avoiding hoarseness, aphonia, and vocal cord paralysis. Counter to common surgical perception and educational beliefs, this study demonstrated that right and left RLN anatomical courses do not significantly differ along the trachea. Therefore, ensnarement on either side during a blind mobilization of the cervical esophagus is equally likely to occur.
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Affiliation(s)
- Michael J Herr
- 12325 College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Anatomy and Neurobiology, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - J Macy Cottrell
- 12325 College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Madison Kahl
- 12325 College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Darryl S Weiman
- 12325 College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Surgery, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
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Chao YK. Robotic McKeown esophagectomy with recurrent laryngeal nerve lymph node dissection: how I do it. Dis Esophagus 2020; 33:6006407. [PMID: 33241306 DOI: 10.1093/dote/doaa053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/16/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022]
Abstract
We describe our standardized approach to robotic esophagectomy with special emphasis on the technical aspects pertaining to bilateral recurrent laryngeal nerve lymph node dissection.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
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Chevallay M, Jung M, Chon SH, Takeda FR, Akiyama J, Mönig S. Esophageal cancer surgery: review of complications and their management. Ann N Y Acad Sci 2020; 1482:146-162. [PMID: 32935342 DOI: 10.1111/nyas.14492] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.
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Affiliation(s)
- Mickael Chevallay
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Minoa Jung
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine (NCGM), Tokyo, Japan
| | - Stefan Mönig
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Pu S, Chen H, Zhou C, Yu S, Liao X, Zhu L, He J, Wang B. Major Postoperative Complications in Esophageal Cancer After Minimally Invasive Esophagectomy Compared With Open Esophagectomy: An Updated Meta-analysis. J Surg Res 2020; 257:554-571. [PMID: 32927322 DOI: 10.1016/j.jss.2020.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/30/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND To evaluate the existing literature comparing cardiopulmonary complications after minimally invasive esophagectomy (MIE) with open esophagectomy (OE) and conduct a meta-analysis based on the relevant studies. METHODS A systematic search for articles was performed in Medline, Embase, Wiley Online Library, and the Cochrane Library. The relative risks or odds ratios (ORs) were calculated by using fixed or random-effects models. The I2 and X2 tests were used to test for statistical heterogeneity. We performed a metaregression for the pulmonary complications with the adenocarcinoma proportion and tumor stage. Publication bias and small-study effects were assessed using Egger's test and Begg's funnel plot. RESULTS A total of 30,850 participants were enrolled in the 63 studies evaluated in the meta-analysis. Arrhythmia, pulmonary embolism, pulmonary complications, gastric tip necrosis, anastomotic leakage, and vocal cord palsy were chosen as outcomes. The occurrence rate of arrhythmia was significantly lower in patients receiving MIE than in patients receiving OE (OR = 0.69; 95% CI = 0.53-0.89), with heterogeneity (I2 = 30.7%, P = 0.067). The incidence of pulmonary complications was significantly lower in patients receiving MIE (OR = 0.54, 95% CI = 0.45-0.63) but heterogeneity remained (I2 = 72.1%, P = 0.000). The risk of gastric tip necrosis (OR = 1.48, 95% CI = 1.07-2.05) after OE was lower than that after MIE. Anastomotic leakage, pulmonary embolism, and vocal cord palsy showed no significant differences between the two groups. CONCLUSIONS MIE has advantages over OE, especially in reducing the incidence of arrhythmia and pulmonary complications. Thus, MIE can be recommended as the preferred alternative surgery method for resectable esophageal cancer.
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Affiliation(s)
- Shengyu Pu
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Heyan Chen
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Can Zhou
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Shibo Yu
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Xiaoqin Liao
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Lizhe Zhu
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China
| | - Jianjun He
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China.
| | - Bin Wang
- Department of Breast Surgery, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an, Shaan'xi Province, China.
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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: 1.8] [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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Ahmadinejad M, Soltanian A, Maghsoudi LH. Risk factors and therapeutic measures for postoperative complications associated with esophagectomy. Ann Med Surg (Lond) 2020; 55:167-173. [PMID: 32489659 PMCID: PMC7262474 DOI: 10.1016/j.amsu.2020.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023] Open
Abstract
Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ali Soltanian
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Leila Haji Maghsoudi
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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Amano S, Shibasaki S, Tomatsu M, Nakamura K, Nakauchi M, Nakamura T, Kikuchi K, Kadoya S, Inaba K, Uyama I. Clinical Experience with the Continuous Intraoperative Nerve Monitoring System in Mediastinoscopic Esophagectomy. THE JAPANESE JOURNAL OF GASTROENTEROLOGICAL SURGERY 2020; 53:524-532. [DOI: 10.5833/jjgs.2017.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
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Chen WS, Zhu LH, Li WJ, Tu PJ, Huang JY, You PL, Pan XJ. Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy. World J Gastroenterol 2020; 26:1340-1351. [PMID: 32256021 PMCID: PMC7109273 DOI: 10.3748/wjg.v26.i12.1340] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/27/2020] [Accepted: 03/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications.
AIM To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position.
METHODS The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named “bilateral exposure method”). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018.
RESULTS There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312).
CONCLUSION This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.
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Affiliation(s)
- Wen-Shu Chen
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Li-Huan Zhu
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Wu-Jin Li
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Peng-Jie Tu
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Jian-Yuan Huang
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Pei-Lin You
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
| | - Xiao-Jie Pan
- Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
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Chao YK, Wen YW, Chuang WY, Cerfolio RJ. Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience. Dis Esophagus 2020; 33:5480067. [PMID: 31022725 DOI: 10.1093/dote/doz033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 03/23/2019] [Indexed: 12/11/2022]
Abstract
Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P < 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P = 0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou
| | - Yu-Wen Wen
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou.,Clinical Informatics and Medical Statistics Research Center
| | - Wen-Yu Chuang
- Department of Pathology, Chang Gung Memorial Hospital-Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, USA
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Nakashima Y, Saeki H, Hu Q, Tsuda Y, Zaitsu Y, Hisamatsu Y, Ando K, Kimura Y, Oki E, Mori M. Changing the Dissectable Layer: Novel Thoracoscopic Esophagectomy Method for Lymphadenectomy along the Left Recurrent Laryngeal Nerve. J Am Coll Surg 2020; 230:e1-e6. [DOI: 10.1016/j.jamcollsurg.2019.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/23/2019] [Accepted: 10/08/2019] [Indexed: 12/13/2022]
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Li X, Wang Z, Zhang G, Fu J, Wu Q. T-shaped linear-stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy: a pilot study. TUMORI JOURNAL 2020; 106:506-509. [PMID: 31955641 DOI: 10.1177/0300891619898531] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has become a good option in the surgical treatment of esophageal cancer. Cervical esophagogastric anastomoses (CEGA) are widely used during esophagectomy. However, CEGA are related with a higher incidence of anastomotic complications. In the present study, a new procedure of T-shaped linear-stapled cervical esophagogastric anastomosis was used during MIE and the short-term outcomes are presented. METHODS From May 2014 to December 2018, 32 consecutive patients with esophageal cancer who underwent total MIE followed by T-shaped linear-stapled cervical esophagogastric anastomosis were included. Postoperative outcomes were analyzed. RESULTS Fifteen men and 17 women were included this pilot study. The histology of all cases was squamous cell carcinoma. Mean operation time of T-shaped linear-stapled cervical esophagogastric anastomosis was 17.6 minutes. There were no early or late mortalities. A minor cervical anastomotic leakage occurred in 1 patient. No complications of anastomotic stenosis occurred in this study. CONCLUSION The T-shaped linear-stapled cervical esophagogastric anastomosis is efficient, reliable, easy to perform, and associated with lower postoperative complication rate.
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Affiliation(s)
- Xinju Li
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhe Wang
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guangjian Zhang
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Junke Fu
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qifei Wu
- Department of Thoracic Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 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: 0.2] [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: 2.0] [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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Zhang S, Zhang P, Guo S, Lian J, Chen Y, Chen A, Ma Y, Li F. Comparative study of three types of lymphadenectomy along the left recurrent laryngeal nerve by minimally invasive esophagectomy. Thorac Cancer 2019; 11:224-231. [PMID: 31860783 PMCID: PMC6997020 DOI: 10.1111/1759-7714.13210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/14/2019] [Accepted: 09/14/2019] [Indexed: 12/14/2022] Open
Abstract
Background The objective of this study was to compare three kinds of lymphadenectomy methods along the recurrent laryngeal nerve (RLN) and assess the safety and effectiveness of the new method. Methods A total of 194 patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) at our institution from May 2013 to May 2017 were analyzed retrospectively. According to the method of lymphadenectomy along the left RLN, the patients were divided into three groups: 75 cases underwent the conventional method (A group), 80 cases the skeletonized method (B group) and 39 cases the modified Bascule method (C group). The number of dissected lymph nodes and surgical outcomes were recorded and compared to identify differences among the three groups. Results The frequency of metastasis to the LRLN lymph node was 18.6% among all patients, and 12%, 20% and 28% in groups A, B and C, respectively. The number of harvested lymph nodes (total/chest/LRLN/LRLN+) in group B and group C were significantly greater than that of group A, but not significant between group B and group C. The hoarseness rate in group C was 15.4%, which was lower than the rate in group B (21.3%) and higher than the rate in group A (13.3%), but there was no statistical significance. Conclusions The new method for lymphadenectomy along the left RLN during MIE in the semi‐prone position is safe and reliable. It provides sufficient lymph node dissection along the left RLN.
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Affiliation(s)
- Shuangping Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China.,Department of Thoracic Surgery, Shanxi Cancer Hospital, Taiyuan, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Shiping Guo
- Department of Thoracic Surgery, Shanxi Cancer Hospital, Taiyuan, China
| | - Jianhong Lian
- Department of Thoracic Surgery, Shanxi Cancer Hospital, Taiyuan, China
| | - Yun Chen
- Department of Cleaning & Sterilization, Shanxi Cancer Hospital, Taiyuan, China
| | - Ailan Chen
- Department of Cleaning & Sterilization, Shanxi Cancer Hospital, Taiyuan, China
| | - Yong Ma
- Department of Thoracic Surgery, Shanxi Cancer Hospital, Taiyuan, China
| | - Feng Li
- Department of Thoracic Surgery, Shanxi Cancer Hospital, Taiyuan, 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: 2.2] [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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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: 1.2] [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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Chao YK, Li ZG, Wen YW, Kim DJ, Park SY, Chang YL, van der Sluis PC, Ruurda JP, van Hillegersberg R. Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE): study protocol for a randomized controlled trial. Trials 2019; 20:346. [PMID: 31182150 PMCID: PMC6558787 DOI: 10.1186/s13063-019-3441-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/13/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Radical lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is surgically demanding and can be associated with substantial postoperative morbidity. The question of whether robot-assisted esophagectomy (RE) might be superior to video-assisted thoracoscopic esophagectomy (VATE) for performing LND along the RLN in patients with esophageal squamous cell carcinoma (ESCC) remains open. METHODS/DESIGN We will conduct a multicenter, open-label, randomized controlled trial (Robotic-assisted Esophagectomy vs Video-Assisted Thoracoscopic Esophagectomy (REVATE)) enrolling patients with ESCC scheduled to undergo LND along the RLN. Patients will be randomly assigned to either RE or VATE. The primary outcome measure will be the rate of unsuccessful LND along the left RLN, which will be defined as: failure to remove lymph nodes along the left RLN (i.e., no identifiable nodes on pathology reports); or occurrence of permanent (duration > 6 months) left RLN palsy following LND. Secondary outcomes will include the number of successfully removed RLN nodes, postoperative recovery, length of hospital stay, 30-day and 90-day mortality, quality of life, and oncological outcomes. DISCUSSION The REVATE study provides an opportunity to explore whether RE could facilitate LND along the left RLN-a complex surgical procedure that, as of now and with the use of VATE, remains difficult to perform and associated with a significant burden of morbidity. TRIAL REGISTRATION ClinicalTrials.gov, NCT03713749 . Registered on 22 October 2018.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Zhi-Gang Li
- Division of Thoracic Surgery Shanghai Chest Hospital, Shanghai, China
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center Chang Gung University, Taoyuan, Taiwan
| | - Dae-Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong-Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu-Ling Chang
- School of Nursing, Chang Gung University, Taoyuan, Taiwan
| | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Jin Y, Lu X, Xue L, Zhao X. Retrospective Comparison of Two Minimally Invasive Esophagectomy in the Treatment of Esophageal Cancer: Pneumatic Mediastinoscopy Versus Thoracoscopy. J Laparoendosc Adv Surg Tech A 2019; 29:638-642. [PMID: 30562122 DOI: 10.1089/lap.2018.0512] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Yuxiang Jin
- Department of Thoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Xinye Lu
- Department of Thoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Lei Xue
- Department of Thoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
| | - Xuewei Zhao
- Department of Thoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, P.R. China
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Comparison of Long-term Quality of Life in Patients with Esophageal Cancer after Ivor-Lewis, Mckeown, or Sweet Esophagectomy. J Gastrointest Surg 2019; 23:225-231. [PMID: 30298418 DOI: 10.1007/s11605-018-3999-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/26/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study was to compare the long-term quality of life (QoL) in patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy. METHODS Esophageal cancer patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy from 2010 to 2012 were included. QoL was assessed according to the European Organization for Research and Treatment of Cancer general questionnaire: QLQ-C30 and esophagus-specific questionnaire: QLQ-OES18. RESULTS A total of 126 qualified patients who have been alive for more than 3 years without tumor recurrence were divided into three groups: the Sweet group (n = 40), Ivor-Lewis group (n = 38), and Mckeown group (n = 48). Among these three groups, the QLQ-C30 mean scores of global health status, functional and symptom scales, and general QoL were similar. The symptom scales of QLQ-OSE18 showed that patients who had a Mckeown operation experienced more problem of eating (P = 0.029), choking when swallowing (P = 0.010) and coughing (P = 0.016), while patients undergoing Sweet operation complained more symptom of reflux (P = 0.003) and pain (P = 0.000). CONCLUSIONS All three types of esophagectomy provided a generally good long-term QoL. However, patients in Sweet and Mckeown group tend to suffer from a higher symptomatic burden as compared to Ivor-Lewis approach.
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Wang P, Li Y, Sun H, Zhang R, Liu X, Liu S, Wang Z, Zheng Y, Yu Y, Chen X, Li H, Zhang J, Liu Q. Analysis of the associated factors for severe weight loss after minimally invasive McKeown esophagectomy. Thorac Cancer 2019; 10:209-218. [PMID: 30578600 PMCID: PMC6360231 DOI: 10.1111/1759-7714.12934] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND This study investigated the risk factors for severe weight loss (SWL) within one year after minimally invasive McKeown esophagectomy. METHODS Esophageal cancer patients who underwent McKeown esophagectomy between January and July 2017 were prospectively enrolled. Preoperative body weight (PBW) was chosen as the initial body weight. RESULTS Forty-four patients were enrolled and successfully followed up for one year. Median weight loss was 7.4% (quartile: 5.3-8.1%) and 12.6% (quartile: 8.8-17.7%) four weeks and one year after surgery, respectively. Accelerated weight loss occurred during the first two weeks after discharge, with median weight loss of 5.6% (quartile: 4.2-7.1%). Multivariable analysis showed that age ≥ 70 years (odds ratio [OR] 7.65; P = 0.030), preoperative sarcopenia (OR 7.18; P = 0.030), the first surgery in the daily schedule (OR 6.87; P = 0.032) and vocal cord paralysis (OR 12.30; P = 0.046) were independent risk factors for short-term (4 weeks) SWL (> 7.5% PBW), while an American Society of Anesthesiologists score of 3-4 (OR 6.58; P = 0.047), a high fat-free mass (OR 21.91; P = 0.003), and vocal cord paralysis (OR 25.83; P = 0.017) were independent risk factors for long-term (1 year) SWL (> 13.0% PBW) after esophagectomy. Postoperative symptoms of insomnia, appetite loss, dysphagia, eating difficulties, and taste issues were also related to SWL. CONCLUSIONS In esophageal cancer patients who have undergone esophagectomy, the first two weeks after hospital discharge is a key period for nutrition intervention. Patients with associated factors for SWL require postoperative nutrition support.
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Affiliation(s)
- Peiyu Wang
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Yin Li
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
- Department of Thoracic Surgical OncologyNational Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Haibo Sun
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Ruixiang Zhang
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Xianben Liu
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Shilei Liu
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Zongfei Wang
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Yan Zheng
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Yongkui Yu
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Xiankai Chen
- Department of Thoracic Surgical OncologyNational Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Haomiao Li
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Jun Zhang
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
| | - Qi Liu
- Department of Thoracic SurgeryThe Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer HospitalZhengzhouChina
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“Energy-less technique” with mini-clips for recurrent laryngeal nerve lymph node dissection in prone thoracoscopic esophagectomy for esophageal cancer. Am J Surg 2018; 216:1212-1214. [DOI: 10.1016/j.amjsurg.2017.10.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 09/21/2017] [Accepted: 10/12/2017] [Indexed: 01/05/2023]
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