[Right-sided upper lobectomy in a patient with right aortic arch: a case report and literature review]. / Verkhnyaya lobektomiya sprava u patsienta s pravostoronnei dugoi aorty: sluchai iz praktiki s kratkim obzorom literatury.

A right aortic arch is an anomaly of prenatal development characterized by location of aortic arch to the right from tracheal-esophageal complex. This variant of anatomy is usually asymptomatic and diagnosed accidentally. We performed open upper lobectomy for cancer of the upper lobe of the right lung in a patient with aortic arch dextraposition. Classical right-sided upper lobectomy in patients with right aortic arch is associated with certain difficulties. The most difficult objective is total excision of lymph nodes because trachea is hidden under aortic arch. A specific complication may be postoperative hoarseness associated with iatrogenic damage to the right recurrent laryngeal nerve.

Learning Curve of Robot-Assisted Lymph Node Dissection of the Left Recurrent Laryngeal Nerve: A Retrospective Study of 417 Patients.

OBJECTIVE: Left recurrent laryngeal nerve (no.106recL) lymph node dissection is a challenging procedure, and robotic-assisted minimally invasive esophagectomy (RAMIE) may have some advantages. This study aimed to determine the learning curve of no.106recL lymph node dissection. METHODS: The data of 417 patients who underwent McKeown RAMIE between June 2017 and June 2022 were retrospectively analyzed. The lymph node harvest of no.106recL was used to determine the learning curve, and the cumulative sum (CUSUM) method was employed to obtain the inflection point. RESULTS: A total of 404 patients (404/417, 96.9%) underwent robotic surgery. Based on the number of no.106recL lymph nodes harvested, the CUSUM learning curve was mapped and divided into three phases: phase I (1‒75 cases), phase II (76‒240 cases), and phase III (241‒404 cases). The median (IQR) number of no.106recL lymph node harvests were 1 (4), 3 (6,) and 4 (4) in each phase (p < 0.001). The lymph node dissection rate gradually increased from 62.7% in phase I to 82.9% in phase III (p = 0.001). The total and thoracic lymph node harvest gradually increased (p < 0.001), whereas operation time (p = 0.001) and blood loss gradually decreased (p < 0.001). Moreover, the incidence of total complication (p = 0.020) and recurrent laryngeal nerve injury (p = 0.001) significantly decreased, and the postoperative hospital stay gradually shortened (p < 0.001). CONCLUSION: Robotic no.106recL lymph node dissection has some advantages for patients with esophageal cancer. In this study, perioperative and clinical outcomes were significantly improved over the learning curve. However, further prospective studies are required to confirm our results.

Shaving Papillary Thyroid Carcinoma Involving Functioning Recurrent Laryngeal Nerve: Safety of Incomplete Tumor Resection and Nerve Sparing.

BACKGROUND: Whether to sacrifice or spare the recurrent laryngeal nerve (RLN) when papillary thyroid carcinoma (PTC) involves a functioning RLN remains controversial. Oncological outcomes after shaving PTC with gross remnant on the RLN have been rarely reported. The objective of this study was to evaluate the oncological outcomes of patients who underwent shaving of a PTC from the RLN, leaving a gross residual tumor with the intent of vocal function preservation. METHODS: A retrospective, cohort study was conducted in 47 patients who were determined to have PTC invasion of the RLN via intraoperative inspection and underwent tumor shaving with macroscopic remnant (R2 resection) less than 1 cm in length and 4 mm in thickness. Median follow-up period was 93 (range, 60-215) months. The primary endpoint was the recurrence-free survival and the progression-free survival. Secondary endpoints were biochemical outcomes (serum thyroglobulin) and vocal cord function. RESULTS: Of the 47 patients, five (10.6%) patients showed recurrence (central neck, 3; lateral neck, 2) without death or distant metastasis. The RLN was resected along with the tumor in one (2.1%) patient who presented with progression of the residual tumor. Postoperative temporary vocal cord paralysis occurred in six (12.8%) patients without permanent cases. The final nonstimulated serum thyroglobulin was 0.7 ± 1.8 ng/ml. CONCLUSIONS: Shaving a tumor from a RLN with gross residual disease may be considered an alternative strategy to preserve vocal function when complete tumor resection with nerve preservation is impossible in patients with PTC invading a functioning RLN.

Lymph Node Posterior to the Right Recurrent Laryngeal Nerve Metastasis in Right Lobe T1a Papillary Thyroid Carcinoma: A Retrospective Cohort Study.

INTRODUCTION AND OBJECTIVES: This study analyzed the incidence and predictors of lymph node posterior to the right recurrent laryngeal nerve metastasis in T1a papillary thyroid carcinoma of the right lobe. METHODS: This was a retrospective cohort study. Patients were selected from those who had received surgical treatment for primary papillary thyroid carcinoma between January 2019 and December 2020. The association between clinicopathologic variables and lymph node posterior to the right recurrent laryngeal nerve metastasis was assessed using univariate and multivariate analyses. Postoperative complications were also described. RESULTS: Lymph node posterior to the right recurrent laryngeal nerve metastasis was present in 6.0% of the 402 study patients. It was the most likely to occur when there were other lymph node metastases, particularly in the lymph node anterior to the recurrent laryngeal nerve. Independent predictors for lymph node posterior to the right recurrent laryngeal nerve metastasis were a tumor size of ≥5.0 mm, a lower pole location, and lymph node anterior to the right recurrent laryngeal nerve metastasis. The rate of persistent vocal cord paralysis was .5%, and no patient developed permanent hypoparathyroidism. CONCLUSIONS: Although lymph node posterior to the right recurrent laryngeal nerve metastases of the right lobe T1a papillary thyroid carcinoma is uncommon, the possibility of metastasis should be investigated when there is a positive lymph node anterior to the right recurrent laryngeal nerve in a tumor >5.0 mm in size located in the lower pole. Lymph node posterior to the right recurrent laryngeal nerve dissection is recommended for such tumors.

Robotic esophagectomy with outermost layer-oriented dissection for esophageal cancer: technical aspects and a retrospective review of a single-institution database.

BACKGROUND: Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC). METHODS: Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed. RESULTS: Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m2. Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively. CONCLUSION: RE with the outermost layer-oriented approach can provide safe short-term outcomes.

A novel technique for lymphadenectomy along the left recurrent laryngeal nerve during minimally invasive esophagectomy: a retrospective cohort study.

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.

[Characteristics of lymph node metastasis of right recurrent laryngeal nerve in thoracic esophageal squamous cell carcinoma].

Objective: To understand the characteristics and influencing factors of lymph node metastasis of the right recurrent laryngeal nerve in thoracic esophageal squamous cell carcinoma (ESCC), and to explore the reasonable range of lymph node dissection and the value of right recurrent laryngeal nerve lymph node dissection. Methods: The clinicopathological data with thoracic ESCC were retrospectively analyzed, and the characteristics of lymph node metastasis along the right recurrent laryngeal nerve and its influencing factors were explored. Results: Eighty out of 516 patients had lymph node metastasis along the right recurrent laryngeal nerve, the metastasis rate was 15.5%. Among 80 patients with lymph node metastasis along the right recurrent laryngeal nerve, 25 cases had isolated metastasis to the right recurrent laryngeal nerve lymph node but no other lymph nodes. The incidence of isolated metastasis to the recurrent laryngeal nerve lymph node was 4.8% (25/516). A total of 1 127 lymph nodes along the right recurrent laryngeal nerve were dissected, 115 lymph nodes had metastasis, and the degree of lymph node metastasis was 10.2%. T stage, degree of tumor differentiation and tumor location were associated with right paraglottic nerve lymph node metastasis (all P<0.05). The lymph node metastasis rate along the right recurrent laryngeal in patients with upper thoracic squamous cell carcinoma (23.4%, 26/111) was higher than that of patients with middle (13.5%, 40/296) and lower (12.8%, 14/109) thoracic squamous cell carcinoma (P=0.033). In patients with poorly differentiated ESCC (20.6%, 37/180) the metastasis rate was higher than that of patients with moderately (14.6%, 39/267) and well-differentiated (5.8%, 4/69; P<0.05). The lymph node metastasis rate of patients with stage T4 (27.3%, 3/11) was higher than that of patients with stage T1 (9.6%, 19/198), T2 (19.0%, 16/84) and T3 (18.8%, 42/1 223; P<0.05). Multivariate regression analysis showed that tumor location (OR=0.61, 95% CI: 0.41-0.90, P=0.013), invasion depth (OR=1.46, 95% CI: 1.11-1.92, P=0.007), and differentiation degree (OR=1.67, 95% CI: 1.13-2.49, P=0.011) were independent risk factors for lymph node metastasis along right recurrent laryngeal nerve of ESCC. Conclusions: The lymph node along the right recurrent laryngeal nerve has a higher rate of metastasis and should be routinely dissected in patients with ESCC. Tumor location, tumor invasion depth, and differentiation degree are risk factors for lymph node metastasis along right recurrent laryngeal nerve in patients with ESCC.

[Establishment and validation of a nomogram model for evaluating the metastasis of lymph nodes posterior to the right recurrent laryngeal nerve in papillary thyroid carcinoma].

Objective: To explore the related factors of lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) metastasis in papillary thyroid carcinoma (PTC) and establish a nomogram model for evaluating LN-prRLN metastasis. Methods: The clinical data of patients with PTC who underwent surgery in the Department of Thyroid Surgery of the First Affiliated Hospital of Zhengzhou University from January 2020 to December 2021 were retrospectively analyzed. Multivariate logistic regression was used to analyze the related factors of LN-prRLN metastasis and construct a nomogram model for evaluating LN-prRLN metastasis. Meanwhile, the data of 120 patients from January to June 2022 were also collected for external verification. Results: A total of 466 patients with PTC were enrolled, including 106 males and 360 females, and aged 44 (33, 53) years. There were 280 cases in the training group and 186 cases in the internal validation group, respectively. Multivariate logistic regression analysis showed that age (OR=0.966, 95%CI: 0.938-0.996, P=0.027), tumor size (OR=1.048, 95%CI: 1.001-1.098, P=0.043), multifocality (OR=2.459, 95%CI: 1.268-4.767, P=0.008), right central lymph node metastasis reported by ultrasound (OR=3.099, 95%CI: 1.255-7.651, P=0.014), extrathyroid extension (OR=3.561, 95%CI: 1.255-10.102, P=0.017) and serum thyroglobulin level (OR=1.010, 95%CI: 1.001-1.018, P=0.032) were related factors for LN-prRLN metastasis. The area under the curve (AUC) values of receiver operating characteristic (ROC) curves of the training group, internal validation group and external validation group were 0.765 (95%CI: 0.691-0.840), 0.747 (95%CI: 0.657-0.837) and 0.754 (95%CI: 0.639-0.869), respectively. Conclusion: Dissection of the LN-prRLN is recommended for young PTC patients with large tumor size, multifocality, right central lymph node metastasis reported by ultrasound, extrathyroid extension and high serum thyroglobulin level.

[Preliminary analysis of neuroprotective effects of capillary fascia preservation recurrent laryngeal nerve anatomical method in right level â ¥ dissection].

Objective: To investigate the application and effect of capillary fascia preservation between the recurrent laryngeal nerve (RLN) and common carotid artery (fascia preservation method) in nerve protection when dissecting right level Ⅵ lymph nodes for patients with papillary thyroid carcinoma. Methods: A retrospective cohort study enrolling 195 patients with papillary thyroid carcinoma undergoing right level Ⅵ lymph node dissection in Beijing Tongren Hospital from March 2021 to August 2022 was carried out. The RLN was dissected by fascia preservation method in study group and by routine method in control group. The intraoperative electrical signal amplitude of the RLN, the number of dissected lymph nodes, and the postoperative complications were recorded and analyzed. Results: A total of 195 patients (study group: 94 cases, control group: 101 cases) were collected. There were 71 males and 124 females, with the median age of 32 (39, 51) years. In the study group, the total number of right level Ⅵ lymph nodes was significantly larger than the number of right Ⅵa level lymph nodes [8 (6, 11) vs 6 (4, 8), P<0.001]. There were no significant differences between the two groups in the number of level Ⅵa or level Ⅵb lymph nodes [Ⅵa: 6 (4, 8) vs 5 (3, 7), P=0.373; Ⅵb: 3 (1, 4) vs 2 (1, 4), P=0.337] and metastasis rate [Ⅵa: 51.1% (48/94) vs 52.5% (53/101), P=0.844; Ⅵb: 12.8% (12/94) vs 15.8% (16/101), P=0.541]. The ratio of electromyography (EMG) amplitude R2 in lower level Ⅵ and entry into larynx (grouped as>90%, 50%~90%,<50%) in the study group was significantly higher than that in the control group (P<0.001). No significant differences were detected between the two groups in temporary RLN paralysis [1.1% (1/94) vs 2.0% (2/101), P=1.000]. Conclusions: Fascia preservation method can decrease the stimulus and traction to RLN and preserve the capillary network serving RLN. It can thoroughly dissect lymph nodes and decrease the injury of RLN.

Histological study of the thin membranous dense connective tissues around the curving portion of the bilateral recurrent laryngeal nerves.

OBJECTIVE/AIM: We aimed to demonstrate the anatomical relationship between the recurrent laryngeal nerves (RLNs), thin membranous dense connective tissue (TMDCT [e.g., the visceral or vascular sheaths around the esophagus]), and the lymph nodes around the esophagus at the curving portion of the RLNs for rational and efficient lymph node dissection. METHODS: Transverse sections of the mediastinum at 5 mm or 1 mm intervals were obtained from four cadavers. Hematoxylin and eosin staining and Elastica van Gieson staining were performed. RESULTS: The visceral sheaths could not be clearly observed the curving portions of the bilateral RLNs, which were observed on the cranial and medial side of the great vessels (aortic arch and right subclavian artery [SCA]). The vascular sheaths could be clearly observed. The bilateral RLNs diverged from the bilateral vagus nerves, which ran along with the vascular sheaths, went up around the caudal side of the great vessels and the vascular sheath, and ran cranially on the medial side of the visceral sheath. Visceral sheaths were not observed around the region containing the left tracheobronchial lymph nodes (No. 106tbL) or the right recurrent nerve lymph nodes (No. 106recR). The regions containing the left recurrent nerve lymph nodes (No. 106recL) and the right cervical paraesophageal lymph nodes (No. 101R) were observed on the medial side of the visceral sheath, with the RLN. CONCLUSION: The recurrent nerve, which branched off from the vagus nerve descending along the vascular sheath, ascended the medial side of the visceral sheath after inversion. However, no clear visceral sheath could be identified in the inverted area. Therefore, during radical esophagectomy, the visceral sheath along No. 101R or 106recL may be recognized and available.

The role of magnetic anchoring and traction technique in thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve.

BACKGROUND: Dissecting lymph nodes along the left recurrent laryngeal nerve (LRLN) is the most challenging step in thoracoscopic-assisted esophagectomy. To retract the proximal esophagus in the existing lymphadenectomy methods, either a special trocar is required to insert and take out endoscopic instruments or thoracic punctures are needed to externally retract the esophageal loop. Therefore, advanced skills for esophageal traction are important to facilitate the LRLN lymphadenectomy and to reduce the incidence of trauma to the chest wall. Herein, we present the magnetic anchoring and traction technique, a novel method for LRLN lymphadenectomy during thoracoscopic esophagectomy. METHODS: The magnetic anchoring traction system was successfully used to retract the upper thoracic esophagus and to help expose the upper mediastinum in 10 cases of thoracoscopic-assisted esophagectomy. When the external magnet was moved outside of body, the internal magnet was coupled with a magnetic force to pull the proximal esophagus to the appropriate direction, which helped to expose the LRLN and adjacent lymph nodes. The lymph nodes adjacent to the LRLN could then be dissected completely without any damage to the nerve. RESULTS: In all surgeries, the LRLN and adjacent lymph nodes were well visualized, and the number of trocars used to pass endoscopic instruments for retraction of the proximal esophagus or the number of thoracic punctures for external traction of the esophagus during the surgery were reduced. CONCLUSIONS: In thoracoscopic-assisted esophagectomy, the magnetic anchoring and traction technique can improve the exposure of the LRLN, facilitate LRLN lymphadenectomy, and reduce chest wall trauma.

Impact of prior thoracoscopic experience on the learning curve of robotic McKeown esophagectomy: a multidimensional analysis.

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.

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

BACKGROUND: Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. METHODS: This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. RESULTS: The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. CONCLUSION: IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.

A Review of Microsurgical Resection of Recurrent Laryngeal Neurilemmoma Under Nerve Monitoring.

BACKGROUND: Laryngeal neurilemmoma, especially recurrent laryngeal neurilemmoma, is a rare neural sheath tumor in head and neck. The most common symptom of laryngeal neurilemmoma is hoarseness or dysphonia, followed by dysphagia, dyspnea, and foreign body sensation. At present, surgical resection is the most effective treatment for this kind of tumor, thus making how to remove it become the most concerned problem of surgeons. CASE PRESENTATION: On February 18, 2021, a 64-year-old male presented to our clinic with recurrent sore throat and intermittent hoarseness for 3 years. The results of electronic laryngoscope and magnetic resonance imaging showed a 25×10×21 mm well-defined tumor in the left pyriform sinus without laryngeal cartilage destruction and enlarged lymph nodes. After the initial diagnosis of recurrent laryngeal neurilemmoma, to preserve the continuity of recurrent laryngeal nerve as much as possible, the authors determine to perform anatomical resection of recurrent laryngeal neurilemmoma with operating microscope under the monitoring of recurrent laryngeal nerve function. Finally, the patient recovered completely from hoarseness during postoperative follow-up. CONCLUSION: A complete diagnosis and treatment process of recurrent laryngeal neurilemmoma was presented by the case. Particularly, it shows the application of recurrent laryngeal nerve monitoring in the operation helps to protect the continuity of the recurrent laryngeal nerve, which lays a anatomical bases for the follow-up nerve repair.

[The value and related complications of lymph node dissection along bilateral recurrent laryngeal nerves in esophageal cancer patients].

Esophageal cancer is one of the most common malignant tumors of digestive tract, lymph node metastasis is a frequently encountered metastasis in the esophageal cancer patients. The number of lymph node metastasis is reported as an important prognostic factor, and it also affects the choice of postoperative treatments in the esophageal cancer. It was reported that the recurrent laryngeal nerve lymph nodes are the most common sites of nodal metastasis and need to be completely dissected during the esophagectomy for thoracic esophageal cancers. Dissection of the lymph nodes along bilateral recurrent laryngeal nerves not only improves the accuracy of staging, but also improves postoperative survival of esophageal cancer patients due to reducing the local recurrence. However, it also brings problems such as injury of laryngeal recurrent nerves, and increases postoperative complications such as pulmonary complications and malnutrition due to aspiration and coughing. Therefore, it is necessary to preserve the structure and function of bilateral recurrent laryngeal nerves during esophagectomy through careful manipulations, and minimize the impact of complications in prognosis and quality of life from injury to the recurrent laryngeal nerve.

[Clinical characteristics and prognosis in papillary thyroid carcinoma patients with recurrent laryngeal nerve invasion].

Objective: To investigate the clinical characteristics and risk factors of postoperative recurrence in papillary thyroid carcinoma (PTC) patients with recurrent laryngeal nerve (RLN) invasion. Methods: The data of PTC patients with recurrent laryngeal nerve invasion treated in Beijing Tongren Hospital, Capital Medical University from January 2006 to December 2019 were retrospectively analyzed. The acoustic parameters were compared between different subgroups. Kaplan-Meier method was used to calculate the overall survival (OS) and the recurrence-free rate (RFS), and univariate and multivariate Cox regression analyses were performed to determine the risk factors for postoperative recurrence. Results: A total of 150 PTC patients were enrolled in the final analysis, including 102 females and 48 males, with an average age of (53.5±13.7) years, and 62 patients (41.3%) aged over 55 years. There were 88 cases with stage Ⅰ, and 62 cases with stage Ⅲ. Fifty-five patients presented with preoperative vocal cord paralysis. There were 75 cases appearing adhesion between tumor or lymph node and recurrent laryngeal nerve while 75 cases presented with direct invasion. The comparisons of acoustic parameters showed that patients with RLN invasion had higher jitter compared with patients without RLN invasion [2.3% (1.4%, 3.2%) vs 1.8% (0.8%, 2.6%), P<0.001]. Moreover, patients with preoperative vocal cord paralysis (VCP) had higher jitter[3.1% (2.2%, 4.6%) vs 2.0% (1.1%, 2.8%), P<0.001] and shimmer [7.1% (4.9%, 9.9%) vs 5.5% (4.2%, 7.3%), P<0.001] and shorter maximum phonation time (MPT) [8.0 (6.0, 10.0) s vs 12.0 (10.0, 15.3) s, P<0.001] compared with patients without preoperative VCP. However, there was no statistical difference in acoustic parameters between cases with RLN adhesion and RLN invasion (all P>0.05). Postoperative follow-up time ranged between 12-196 months, with an average of (65.0±35.9) months. Sixteen patients (10.7%) had recurrence or metastasis, and 8 cases (5.3%) died of recurrence or metastasis. The 5-year OS rate was 95.1%, and the 10-year OS rate was 92.8%. The 5-year RFS rate was 88.9%, and the 10-year RFS rate was 86.2%. Univariate Cox analysis showed that age of onset ≥ 55 years, preoperative recurrent laryngeal nerve palsy, laryngeal, trachea or esophageal invasion were the risk factors for postoperative recurrence of PTC with RLN invasion (all P<0.05). Multivariate Cox analysis showed that age of onset ≥ 55 years (OR=1.060, 95%CI: 1.011-1.110, P=0.015) was an independent risk factor. Conclusions: Age of onset ≥ 55 years is an independent risk factor for postoperative recurrence in PTC patients with RLN invasion. Preoperative acoustic parameters may provide reference for evaluation of RLN function.

Postoperative recurrent laryngeal nerve palsy is associated with pneumonia in minimally invasive esophagectomy for esophageal cancer.

BACKGROUND: During the past decade, minimally invasive esophagectomy (MIE) for esophageal cancer has been adopted worldwide with expectations of lower invasiveness. However, the rate of postoperative pneumonia, which is an independent risk factor for oncological prognosis in esophageal cancer, remains high. The aim of this retrospective follow-up study is to clarify whether there is a strong correlation between recurrent laryngeal nerve (RLN) palsy and postoperative pneumonia in MIE. METHODS: This retrospective follow-up study included 209 patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position (TEP) at Kobe University between 2011 and 2018. Inclusion criteria included age 18-85 years; cT1-3, cN0-3 disease; upper mediastinal lymphadenectomy; and ability to undergo simultaneous esophagectomy and reconstruction of the gastric conduit or pedicled jejunum. Univariate and multivariate logistic regression were conducted to identify independent risk factors for pneumonia. RESULTS: Among 209 TEPs, pneumonia of Clavien-Dindo classification grade > II occurred in 44 patients (21%). In the pneumonia positive and negative groups, there were significant differences in age (67.9 ± 7.5 vs. 64.9 ± 8.6 years), 3-field lymph node dissection [27 (61%) vs. 67 (41%)], transfusion [20 (45%) vs. 41 (25%)], left RLN palsy [19 (43%) vs. 18 (11%)], and any RLN palsy [20 (45%) vs. 18 (11%)]. In multivariate analysis, any RLN palsy was associated with a higher incidence of pneumonia [odds ratio (OR), 6.210; 95% confidence interval (CI), 2.728-14.480; P < 0.0001]. In addition, age was associated with a higher incidence of pneumonia (OR, 1.049; 95% CI, 1.001-1.103; P = 0.046). Changes in the rate of any RLN palsy over time were quite similar to changes in the incidence of pneumonia. CONCLUSION: There is a strong correlation between RLN palsy and pneumonia in MIE for esophageal cancer. Prevention of RLN palsy may reduce the incidence of pneumonia, leading to better oncological prognosis.

Non-energy devices to dissect recurrent laryngeal nerve lymph nodes of non-small cell lung cancer under video-assisted thoracic surgery.

BACKGROUND: Systematic nodal dissection plays a crucial role in improving survival and staging in resectable non-small cell lung cancer (NSCLC) patients but at the cost of increasing the occurrence of recurrent laryngeal nerve injury. Technology should be improved to protect the recurrent laryngeal nerve (RLN) during surgery. METHODS: NSCLC patients who underwent video-assisted thoracic surgery (VATS) surgical treatment by the same surgeon at our hospital from January 2016 to December 2017 were included as the research subjects and were divided into an energy-device group and a non-energy-device group. Their procedures included anatomic pulmonary resection, normative N1 dissection, and systemic N2 dissection. RESULTS: The rate of metastatically involved recurrent laryngeal nerve lymph nodes (RLNLNs) was 5.19% (39/752). Dissection device, side of primary, FEV1, operative time and BMI were independent predictors of recurrent laryngeal nerve injury (RLNI) (hazard ratio (HR) = 3.576, 95% confidence interval (CI): 1.490-8.583, P = 0.004; HR = 0.175, 95% CI: 0.072-0.424, P = < 0.001; HR = 3.008, 95% CI: 1.30-6.927, P = 0.010; HR = 0.328, 95% CI: 0.136-0.794, P = 0.013; HR = 0.344, 95%CI: 0.147-0.801, P = 0.013, respectively). Patients in the non-energy-device group had significantly less RLNI than the energy-device group (P = 0.016) and nearly half of the non-thermal RLNI recovered in 2 weeks (P = 0.025) whereas most thermal RLNI required 3 months for recovery. CONCLUSIONS: Every station of RLNLN had some degree of cancer metastasis in NSCLC patients and when dissecting RLNLNs, dissection device was an independent and artificially controlled predictor of RLNI. Using a non-energy device is a feasible method to protect the RLN as well as an improved recovery time of RLNI.

Minimally invasive esophagectomy and radical lymph node dissection without recurrent laryngeal nerve paralysis.

BACKGROUND: We introduce a novel operative technique to dissect lymph nodes adjacent to the recurrent laryngeal nerve, referred to as the "native tissue preservation" technique. Using this technique, there was no damage to the recurrent laryngeal nerve, which is maintained in its anatomical position. METHODS: From September 2016 to December 2018, minimally invasive esophagectomy was performed in the left lateral decubitus position in 87 patients with esophageal cancer. The native tissue preservation technique for lymphadenectomy around the recurrent laryngeal nerve was used, and all patients were evaluated for recurrent laryngeal nerve paralysis. RESULTS: Minimally invasive esophagectomy was completed in all patients without conversion to thoracotomy. Although an extended lymphadenectomy was performed in all patients, there were no grade II or higher complications (Clavien-Dindo classification) and no incidence of recurrent laryngeal nerve paralysis. CONCLUSION: The native tissue preservation technique may reduce the incidence of recurrent laryngeal nerve paralysis after minimally invasive esophagectomy with radical lymph node dissection.

Mesenteric excision of upper esophagus: a concept for rational anatomical lymphadenectomy of the recurrent laryngeal nodes in thoracoscopic esophagectomy.

BACKGROUND: The recurrent laryngeal nerve (RLN) lymph nodes are among the most frequently involved lymph nodes in esophageal cancer. Surgical removal of these lymph nodes is considered beneficial for postoperative prognosis, especially in patients with squamous cell carcinoma. Unfortunately, the precise surgical anatomy of the upper mediastinum is not well understood and no distinct high-resolution images are currently available. METHODS: In this article, we provide a simple intuitive concept of upper mediastinal surgical anatomy that could facilitate rational anatomical lymphadenectomy of the RLN lymph nodes. The essential concept of this mesenteric excision is to mobilize mesoesophagus including RLN in an en bloc fashion and to save RLN laterally by incising visceral sheath. This is applicable identically to both right and left upper mediastinum. RESULTS: Between January 2009 and December 2017, thoracoscopic esophagectomy with upper mediastinal lymphadenectomy for primary esophageal cancer was performed in 189 patients. Median thoracoscopic procedure time was 297 (range 205-568) min and median intraoperative blood loss was 70 ml (range unmeasurable up to 2545 ml). Median number of harvested upper mediastinal lymph nodes was 12. Postoperative complication of Clavien-Dindo classification grade III or higher events was observed in 14% of patients. RLN palsy of grade II or higher occurred in 20 patients (11%). CONCLUSION: The mesoesophagus in the upper mediastinum is an anatomical unit surrounded by fibrous connective tissue containing the esophagus, trachea, tracheoesophageal vessels, lymphatic tissue, and RLNs. Thus, mesenteric excision of esophagus is defined to resect this area by sparing trachea and RLNs for rational anatomical lymphadenectomy. We believe that this concept makes upper mediastinal lymphadenectomy safer and more appropriate.