Laryngeal Nerve Lymph Node Dissection Research Articles

Recurrent laryngeal nerve lymph node dissection with subcomplete sealing using advanced bipolar energy device in minimally invasive esophagectomy.

Recurrent laryngeal nerve (RLN) palsy is a complication that must be avoided during esophagectomy. While RLN injury is thought to be caused by thermal spread from electric devices, electric devices are useful to avoid bleeding. When dissecting lymph nodes around RLNs, to seal small vessels, we use subcomplete technique with advanced bipolar. We describe our surgical technique, termed the subcomplete sealing technique, in RLN lymph node dissection. The first step is to perform blunt dissection with forceps on both sides of the esophageal branch near the right RLN. A distance of at least 2 mm from the RLN was preferred. Sealing with advanced bipolar often causes tissue shrinkage, pulling the RLN near the device. To prevent this, sealing should be stopped before reaching completion. Although the sealing was not complete, it was sufficient to seal the small vessels. After subcomplete sealing, the sealed tissues were dissected using laparoscopic scissors. The lymph nodes around left RLN are dissected in the same manner. A total of 76 patients received esophagectomy with the subcomplete technique. Grade IIIa RLN palsy occurred in three cases (3.95%). Over Grade IIIb RLN palsies did not occur. This subcomplete sealing technique can assist surgeons in performing RLN lymph node dissection without bleeding and increasing the rate of RLN palsy.

Managing esophageal squamous cell carcinoma after cervical radiotherapy for a head and neck cancer: esophagectomy remains a viable option.

Managing esophageal squamous cell carcinoma (ESCC) in patients with a history of cervical radiotherapy for a head and neck cancer (HNC) often requires a careful evaluation of esophagectomy due to concerns regarding complications and prognosis. This study evaluates the periesophagectomy and oncological outcomes of such patients. Patients diagnosed with ESCC between January 2010 and August 2023 and who had undergone esophagectomy with cervical anastomosis were retrospectively reviewed. Patients were categorized into two groups based on the presence (group 1) or absence (group 2) of a history of radiotherapy for as HNC. After 1: 2 propensity score matching, the perioperative and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were evaluated. A total of 481 patients, 32 in group 1 and 449 in group 2, were included. After matching, group 1 patients and 64 patients in the group 2 were analyzed. All the patients in group 1 were males, and their mean age was 56years. The median radiation dose was 69Gy. The rates of anastomosis leakage, pneumonia, respiratory failure, and reoperation were comparable between the two groups. However, vocal cord palsy occurred more frequently in group 1, particularly in those with recurrent laryngeal nerve lymph node dissection (37.5%). The 3-year OS (69.6% vs. 75.2%; p = 0.26) and RFS (50.8% vs. 55.9%; p = 0.63) were similar between groups 1 and 2. In conclusion, perioperative and oncological outcomes were comparable between ESCC patients with and without prior HNC radiotherapy, supporting esophagectomy as a feasible option.

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

Surgery for oesophageal squamous cell carcinoma involves dissecting lymph nodes along the recurrent laryngeal nerve. This is technically challenging and injury to the recurrent laryngeal nerve may lead to vocal cord palsy, which increases the risk of pulmonary complications. The aim of this study was to compare the efficacy and safety of robot-assisted oesophagectomy (RAO) versus video-assisted thoracoscopic oesophagectomy (VAO) for dissection of lymph nodes along the left RLN. Patients with oesophageal squamous cell carcinoma who were scheduled for minimally invasive McKeown oesophagectomy were allocated randomly to RAO or VAO, stratified by centre. The primary endpoint was the success rate of left recurrent laryngeal nerve lymph node dissection. Success was defined as the removal of at least one lymph node without causing nerve damage lasting longer than 6 months. Secondary endpoints were perioperative and oncological outcomes. From June 2018 to March 2022, 212 patients from 3 centres in Asia were randomized, and 203 were included in the analysis (RAO group 103; VAO group 100). Successful left recurrent laryngeal nerve lymph node dissection was achieved in 88.3% of the RAO group and 69% of the VAO group (P < 0.001). The rate of removal of at least one lymph node according to pathology was 94.2% for the RAO and 86% for the VAO group (P = 0.051). At 1 week after surgery, the RAO group had a lower incidence of left recurrent laryngeal nerve palsy than the VAO group (20.4 versus 34%; P = 0.029); permanent recurrent laryngeal nerve palsy rates at 6 months were 5.8 and 20% respectively (P = 0.003). More mediastinal lymph nodes were dissected in the RAO group (median 16 (i.q.r. 12-22) versus 14 (10-20); P = 0.035). Postoperative complication rates were comparable between the two groups and there were no in-hospital deaths. In patients with oesophageal squamous cell carcinoma, RAO leads to more successful left recurrent laryngeal nerve lymph node dissection than VAO, including a lower rate of short- and long-term recurrent laryngeal nerve injury. Registration number: NCT03713749 (http://www.clinicaltrials.gov).

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.

Impact of the Extent of Recurrent Laryngeal Nerve Lymphadenectomy on Thoracic Esophageal Squamous Cell Carcinoma: A Real-World Multicenter Study.

To determine the impact of recurrent laryngeal nerve lymph node (RLN-LN) dissection on survival and postoperative complications in patients with oesophageal squamous cell carcinoma (ESCC). Patients with cT1-4N0-3M0 thoracic ESCC who underwent oesophagectomy and two-field lymphadenectomy from three institutions were included. The entire cohort was divided into three groups that underwent the total two-field lymphadenectomy (T-2FL), standard two-field lymphadenectomy (S-2FL), or unilateral RLN-LN dissection plus S-2FL (U-2FL) based on the extent of RLN-LN dissection. Subgroup analyses were also performed and were stratified by treatment modality. Both the U-2FL and T-2FL groups had significantly superior outcomes compared with the S-2FL group (overall survival: U-2FL vs S-2FL: P = 0.002; T-2FL vs S-2FL: P < 0.001; recurrence-free survival: U-2FL vs S-2FL: P = 0.01; T-2FL vs S-2FL: P < 0.001). Moreover, no significant differences were observed between U-2FL and T-2FL regarding overall survival (P > 0.05) and recurrence-free survival (P > 0.05), irrespective of administration of neoadjuvant therapy plus oesophagectomy or upfront oesophagectomy. Additionally, the extent of RLN-LN dissection was not an independent predictor of stage migration (P = 0.14), but was for postoperative nodal upstaging (P = 0.02). Notably, S-2FL brought significantly lowered risk in postoperative complications, especially for RLN palsy, when compared with T-2FL (P = 0.002) but not U-2FL (P = 0.72). Adequacy of RLN-LN dissection is an important prognosticator for improved overall survival and recurrence-free survival in patients with thoracic ESCC. U-2FL may serve as an alternative to T-2FL in selected populations.

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

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. 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. 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). 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.

Analysis of the Clinical Effect of Recurrent Laryngeal Nerve Lymph Node Dissection by Minimally Invasive McKeown Esophagealectomy

Analysis of the Clinical Effect of Recurrent Laryngeal Nerve Lymph Node Dissection by Minimally Invasive McKeown Esophagealectomy

Clinical observation on perioperative complications of minimally invasive Ivor-Lewis and minimally invasive McKeown esophagectomy

Objective: To compare and analyze the perioperative clinical effects of minimally invasive Ivor-Lewis esophagectomy (MIE-Ivor-Lewis) and minimally invasive McKeown esophagectomy (MIE-McKeown). Methods: A total of 147 patients who underwent endoscopic esophageal cancer surgery from April 2018 to August 2019 were selected, including 85 patients undergoing MIE-McKeown surgery and 62 patients undergoing MIE-Ivor-Lewis surgery. The measurement data were expressed as (x±s), the comparison of normally distributed measurement data was performed by independent sample t-test, and the comparison of count data was performed by χ(2) test or Fisher's exact test. Results: The operation time of McKeown (M) group and Ivor-Lewis (IL) group were (219.2±72.4) minutes and (225.8±65.3) minutes. The mediastinal lymph node dissection number of M and IL groups were 13.3±4.8 and 11.6±6.5, respectively. The number of left recurrent laryngeal nerve lymph node dissection were 3.5±1.2 and 3.1±1.4, respectively. The intraoperative blood loss were (178.3±41.3) ml and (163.2±64.1) ml, respectively. The number of patients reoperated for postoperative bleeding were 1 and 0, respectively. The number of patients with postoperative gastric bleeding were 0 and 1, respectively. The postoperative chest tube retention time were (2.8±1.3) days and (3.1±1.2) days, respectively. The number of patients with anastomotic leakage were 7 and 1, respectively. The number of patients with lung infection were 13 and 5, respectively, and with chylothorax were 2 and 1, respectively, without statistically significant difference (P>0.05). The number of patients with hoarseness were 11 and 3, respectively. The total incidence of complication were 41.2% (35/85) and 17.7% (11/62), and the postoperative hospital stay were (14.7±6.5) days and (12.3±2.3) days, with statistical difference (P<0.05). Conclusion: MIE-Ivor-Lewis and MIE-McKeown are safe and effective in treating esophageal cancer, but the complication of MIE-Ivor-Lewis is less than that of MIE-Mckeown, and the perioperative clinical effect of MIE-Ivor-Lewis is better than that of MIE-McKeown.

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

BackgroundThe survival benefits of recurrent laryngeal nerve lymph node dissection (RLNLD) in esophageal squamous cell carcinoma (ESCC) are still under debate, and the prognostic value of unilateral RLNLD has been rarely studied. Therefore, the aim of the present study was to investigate the clinical significance and outcomes of RLNLD in ESCC in a large‐scale cohort study, to shed light on the outcomes of unilateral RLNLD, and to identify the factors that affect the prognostic outcome of RLNLD.MethodsWe retrospectively reviewed 1153 patients with thoracic ESCC who underwent right thoracotomy with lymphadenectomy. The impact of RLNLD on disease‐free survival (DFS) and overall survival (OS) was estimated using the Kaplan–Meier method and Cox proportional hazard models. Inverse probability of treatment weighting (IPTW) was performed to adjust for differences in baseline variables in pairwise comparisons. Subgroup analysis of survival and postoperative complications was conducted for selective RLNLD.ResultsRLN lymph node (LN) metastasis was independently associated with tumor location and most other LN station metastases. RLNLD was an independent prognostic factor for DFS and OS. Both patients who underwent unilateral and bilateral RLNLD had significantly better DFS and OS than the non‐RLNLD patients. Furthermore, pairwise comparisons with IPTW confirmed these results, and we found that patients who underwent bilateral RLNLD had better survival than those who underwent unilateral RLNLD. However, subgroup analysis showed that there was no survival benefit and higher morbidity after bilateral RLNLD for patients with cancer in the lower thoracic esophagus, and elderly and female patients.ConclusionRLN LN metastasis is very frequent in ESCC, and both unilateral and bilateral RLNLD have considerable survival benefits. Selective RLNLD with better survival and lower morbidity was recommend for some defined subgroups.

Analysis of risk factors for posterior laryngeal recurrent nerve metastasis in micropapillary thyroid carcinoma.

Posterior recurrent laryngeal nerve (RLN) lymph node dissection remains controversial in the operation of thyroid cancer, especially in cases of papillary thyroid microcarcinoma (PTMC). The present study aimed to evaluate the risk factors for posterior RLN lymph node metastasis in patients with PTMC. Two hundred and thirty-nine patients pathologically diagnosed with PTMC after surgery between June 2016 and June 2017 were included. Risk factors including age, sex, tumor diameter, multiple tumor focus, membrane invasion and lateral cervical lymph node metastasis condition, were analyzed, and their corresponding OR values were calculated. The results indicated that posterior RLN lymph node metastasis was pathologically identified in 27/239 patients. Membrane invasion (p = 0.024), VIa lymph node metastasis (p < 0.01), and lateral cervical lymph node metastasis (p < 0.01) were considered to be risk factors for posterior RLN lymph node metastasis. It is concluded that membrane invasion, VIa lymph node metastasis, and lateral cervical lymph node metastasis significantly increased the incidence of posterior RLN lymph node metastasis. Complete dissection of the posterior RLN lymph node was essential for patients with these risk factors.

Clinical outcome of patients after recurrent laryngeal nerve lymph node dissection for oesophageal squamous cell carcinoma.

OBJECTIVESRecurrent laryngeal nerve lymph node dissection (LND) has been incorporated into oesophagectomy for patients with oesophageal squamous cell carcinoma, but with uncertain oncological efficacy.METHODSThe data of patients with oesophageal squamous cell carcinoma, including who underwent upfront surgery (surgery group) and those who received neoadjuvant therapy followed by surgery (neoadjuvant chemoradiotherapy group), were retrospectively examined. The overall survival (OS) and disease-free survival (DFS) were compared between patients with and without recurrent laryngeal nerve LND.RESULTSAmong the 312 patients, no significant differences were found in 3-year OS and DFS between patients with and without recurrent laryngeal nerve LND in the entire cohort (OS: 57% vs 52%, P = 0.33; DFS: 47% vs 41%, P = 0.186), or the surgery group (n = 173, OS: 69% vs 58%, P = 0.43; DFS: 52% vs. 48%, P = 0.30) and the neoadjuvant chemoradiotherapy group (n = 139, OS: 44% vs 43%, P = 0.44; DFS: 39% vs 32%, P = 0.27). However, among patients with clinical positive recurrent laryngeal nerve lymph node involvement before treatment, there was significant OS and DFS differences between patients with and without recurrent laryngeal nerve LND (OS: 62% vs 33%, P = 0.029; DFS: 49% vs 26%, P = 0.031).CONCLUSIONSRecurrent laryngeal nerve LND is not a significant prognostic factor in patients with oesophageal squamous cell carcinoma; however, it is associated with better outcomes in patients with pre-treatment radiological evidence of recurrent laryngeal nerve lymph node involvement.

Role of Recurrent Laryngeal Nerve Lymph Node Dissection in Surgery of Early-Stage Esophageal Squamous Cell Carcinoma.

In esophageal cancer surgery, it is difficult to perform thorough dissection of lymph nodes along the recurrent laryngeal nerve (RLN-LN). However, there are limited data regarding the necessity of RLN-LN dissection in surgery for superficial esophageal squamous carcinoma (focused on T1b tumor) and its role in locoregional control and accurate nodal staging. Between 2001 and 2016, 567 patients with pT1N0 and 927 patients with cT1N0 squamous cell carcinoma were identified in a prospectively maintained, single institution esophagectomy registry. Sufficient or insufficient RLN-LN assessment group was defined by receiver operating characteristic curve analysis of the number of RLN-LN harvested. To mitigate bias, inverse probability weighting adjustment and several sensitivity analyses were performed. In the pT1N0 cohort, patients with sufficient (≥ 4) harvested RLN-LNs showed significantly superior 5-year recurrence-free survival (89.1% versus 74.8%, log-rank P < 0.001). Patients with insufficient RLN-LN dissection mainly developed locoregional failure at the upper mediastinal or cervical area (87% of total recurred cases). The survival impact of sufficient RLN-LN dissection was more prominent in subsets of upper-middle thoracic tumors or with deep submucosal invasion. In the analysis on cT1N0 cohort, sufficient RLN-LN assessment conferred a 1.5-fold increase in the discovery of positive-nodal disease (19.4% versus 27.8%, P = 0.008). Adequate RLN-LN dissection during surgery may help reduce the risk of recurrence and enhance the accuracy of nodal staging in early-stage esophageal squamous cell carcinoma. Therefore, meticulous surgical evaluation for this region should not be underrated, particularly in the high-risk subset with lymph node metastasis. Visual Abstract Graphical summary of key study findings. T wo cohorts (pT1 and cT1 ; both mainly comprised T1b ) were analyzed for separate purposes; the former controlled for pathologic stage was primarily analyzed in terms of survival and recurrence hazard, whereas the latter (controlled for clinical was used for stage migration ( and intention to treat analysis. Th e results show the significance of adequate bilateral RLN LN in the surgery for early stage ESCC (particularly those with T1b)T1b), in terms of accurate nodal staging, effective nodal clearance, and reduced regional.

Robotic McKeown esophagectomy with recurrent laryngeal nerve lymph node dissection: how I do it.

We describe our standardized approach to robotic esophagectomy with special emphasis on the technical aspects pertaining to bilateral recurrent laryngeal nerve lymph node dissection.

366 CLINICAL NOMOGRAM MODEL FOR RECURRENT LARYNGEAL NERVE LYMPH NODE METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A RETROSPECTIVE MULTICENTER STUDY

Abstract Recurrent laryngeal nerve lymph node metastasis (RLN LNM) is not rare in patients with esophageal cancer. We aimed to explore the risk factors for RLN LNM and to develop a nomogram predicting the likelihood of RLN LNM in esophageal squamous cell carcinoma (ESCC) patients. Methods We retrospectively reviewed patients with ESCC who underwent esophagectomy as well as recurrent laryngeal nerve lymph node dissection between May 2015 and February 2019 at two different institutions. The patients were divided into negative and positive groups according to the presence of RLN LNM. Risk factors for RLN LNM were evaluated by univariate and multivariate analyses. A nomogram was constructed for presentation of the final model. Results A total of 390 patients with ESCC were included in this study. The differences in tumor location, tumor differentiation, T stage, tumor size and carcinoembryonic antigen (CEA) between the negative (N = 270) and positive groups (N = 120) RLN LNM were significant (P &amp;lt; 0.05). Multivariate analysis indicated that the tumor location (OR = 0.520, 95% CI: 0.361–0.749, P &amp;lt; 0.001), tumor differentiation (OR = 2.279, 95% CI: 1.586–3.276, P &amp;lt; 0.001), T stage (OR = 1.436, 95% CI: 1.029–2.003, P = 0.033), tumor size (OR = 1.781, 95% CI: 1.021–3.106, P = 0.042) and CEA (OR = 1.206, 95% CI: 1.003–1.450, P = 0.046) were independent risk factors for RLN LNM. A nomogram with these variables had good predictive accuracy (c-index: 0.716). Conclusion Tumor location, tumor differentiation, T stage, tumor size and CEA may predict the risk of RLN LNM. We created a nomogram predicting the likelihood of RLN LNM in patients with ESCC.

Application of esophageal wire traction in lymph node dissection during three-hole thoracoscopic McKeown esophagectomy

Introduction The quality of left recurrent laryngeal nerve lymph node dissection is critical in esophageal cancer. We investigated whether esophageal wire traction in three-hole thoracoscopic esophagectomy can improve the same. Material and methods We retrospectively analyzed the data of 98 patients who underwent thoracoscopic esophagectomy in our center from January 2018 to July 2018: 36 patients with esophageal wire traction and 62 patients without traction (control group). The clearance time for left recurrent laryngeal nerve lymph nodes, thoracic bleeding volume, number of left recurrent laryngeal nerve lymph nodes, and complications were recorded. Results The observation group had a shorter clearance time for the left recurrent laryngeal nerve lymph nodes (15.8 ± 6.9 min vs. 20.00 ± 6.2 min), less thoracic bleeding (55.8 ± 30.2 mL vs. 70.7 ± 30.3 mL), and higher number of dissected left recurrent laryngeal lymph nodes (3.3 ± 1.4 vs. 2.5 ± 1.1) than the control group. There was no significant difference in the incidence of anastomotic leakage, pulmonary infection, arrhythmia, chylothorax, and nerve injury. Conclusions Esophageal wire traction shortens the clearance time for the left recurrent laryngeal nerve lymph nodes, reduces thoracic bleeding, and improves the quality of left recurrent laryngeal nerve lymph node dissection in three-hole thoracoscopic esophagectomy.

P154 SAFETY AND ONCOLOGICAL EFFICACY OF BILATERAL RECURRENT LARYNGEAL NERVE LYMPH NODE DISSECTION AFTER NEOADJUVANT CHEMORADIOTHERAPY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Aim 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 The need to dissect RLN lymph nodes in patients who had undergone nCRT is controversial. No data are currently available on the clinical utility and implications of RLN nodal dissection in nCRT-treated patients with esophageal cancer. 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.

PS01.231: EFFICACY OF ARTIFICIAL PNEUMOTHORAX WITH SINGLE-LUMEN TRACHEAL TUBE VENTILATION IN THORACOSCOPIC SUBTOTAL ESOPHAGECTOMY IN THE SEMI- PRONE POSITION

Abstract Background Thoracoscopic esophagectomy for esophageal cancer performed with single-lumen tracheal tube ventilation in the semi-prone position provides the advantages of easier anesthesia induction; easiness of left-sided recurrent laryngeal nerve lymph node dissection; and shortening of the transit time to laparotomy. The aim of this study was to clarify the surgical safety and anesthetic procedure associated with thoracoscopic esophagectomy with single-lumen tracheal tube ventilation by intraoperative monitoring of respiratory status and hemodynamic changes. Methods A total of 30 patients with esophageal cancer who underwent thoracoscopic subtotal esophagectomy at our institute from January 2014 to December 2017 were retrospectively reviewed. Cardiac index (CI), systemic vascular resistance index (SVRI), mean arterial pressure (MAP), partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), end-tidal carbon dioxide pressure (EtCO2), and tidal volume (TV) using FloTrac system were measured. Results There were no significant changes in CI, SVRI, and MAP during artificial pneumothorax. Conversely, PaCO2 and EtCO2 gradually increased during artificial pneumothorax (P &lt; 0.05) and decreased to almost their original levels thereafter. Furthermore, progressive reduction in tidal volume was observed in four cases after anti- side pneumothorax due to the injury of the left pleura with lymph node dissection. The mean TV and mean PaO2 were 0.42 L and 229.0 mmHg during artificial pneumothorax, respectively. Conclusion There was no exaggerated circulatory or ventilatory depression during artificial pneumothorax in the semi-prone position. Artificial pneumothorax with single-lumen tracheal tube ventilation in thoracoscopic subtotal esophagectomy may be a reliable anesthetic procedure. However, further examinations in the future will be necessary to determine its safety. Disclosure All authors have declared no conflicts of interest.

VS01.08: STEPWISE APPROACH FOR ROBOT-ASSISTED THORACOSCOPIC LEFT RECURRENT LARYNGEAL NERVE LYMPH NODE DISSECTION

Abstract Description This video showed the stepwise approach for robot-assisted thoracoscopic left recurrent laryngeal nerve lymph node dissection. With the patient lying in the left semiprone position, a total of five trocars were positioned. Left RLN LND was begun by releasing the right esophagotracheal band. Subsequently, the trachea was gradually rotated clockwise through the application of a gentle pressure on the left edge of the tracheal cartilage with the goal of exposing and releasing the left esophagotracheal band. After the complete release of the bilateral esophagotracheal band, the esophagus was retracted toward the dorsal side with the right first robotic arm. Simultaneously, an assistant rolled back the trachea using a forceps grasping a small piece of gauze, with the aim of improving operative exposure. The left RLN was identified in the middle of the soft tissue between the trachea and the esophagus. Dissection was started from the ventral side RLN nodes and subsequently continued toward the dorsal side until the total skeletonization of the left RLN Disclosure All authors have declared no conflicts of interest.

“Energy-less technique” with mini-clips for recurrent laryngeal nerve lymph node dissection in prone thoracoscopic esophagectomy for esophageal cancer

BackgroundMeticulous recurrent laryngeal nerve (RLN) lymph node dissection in thoracoscopic esophagectomy for esophageal cancer often results in RLN paralysis. MethodsWe had attempted to simply cut the vessels around RLN sharply with scissors without using energy device in order to prevent RLN paralysis. However, these procedures often result in minor bleeding. Since we introduced the use of mini-clips for hemostasis before cutting the vessels with scissors, we herein compared the surgical results between before and after the introduction of use of mini-clips. ResultsWith regard to RLN paralysis, the incidence was 24.0% in the before group; this incidence went down to 5.1% in the after group (P = 0.0259). Moreover, length of hospital stay after surgery was significantly shortened, from 36.1 days to 22.0 days, after the introduction of energy-less techniques with mini-clips (P = 0.0075). ConclusionsOur data demonstrated that this technique contributed to prevent RLN paralysis and to shorten the patient's length of hospital stay.

Recurrent laryngeal nerve lymph node dissection in minimally invasive esophagectomy.

Minimally invasive esophagectomy (MIE) has become increasingly important in the treatment for resectable esophageal cancer. However, it's still controversial about the effects of recurrent laryngeal nerve (RLN) lymph node dissection in MIE. Patient was placed in the lateral prone position. RLN lymph node dissection was performed in MIE. MIE can get comparable results of RLN lymph node dissection as open surgery. The number of dissected lymph nodes is 9.8±4.3 pieces and the time of lymphadenectomy is about 24 mins. RLN lymph node dissection is feasible and safe in MIE. The helpful surgical techniques include clear exposure of RLN, good collaboration with assistant, esophageal suspension, and so on.