Left Recurrent Laryngeal Nerve Palsy Research Articles

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).

Ortner's Syndrome: A Comprehensive Review of Etiology, Clinical Presentation, and Management

Ortner's syndrome, also known as cardiovocal syndrome, is a rare clinical entity characterized by left recurrent laryngeal nerve palsy secondary to cardiovascular pathology. Initially described in the context of left atrial enlargement due to mitral stenosis, the syndrome has since been associated with various cardiac and thoracic abnormalities, including aortic aneurysms, pulmonary hypertension, and congenital heart defects. This review aims to provide an in-depth analysis of Ortner's syndrome, encompassing its etiological factors, pathophysiology, clinical manifestations, diagnostic approaches, and therapeutic strategies. We also discuss the historical evolution of the syndrome's understanding and highlight contemporary advancements in its diagnosis and management. Enhanced awareness and timely recognition of Ortner's syndrome are crucial for appropriate intervention and improved patient outcomes.

ASO Author Reflections: Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

ASO Author Reflections: Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

ASO Visual Abstract: Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

ASO Visual Abstract: Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

Ortner’s Syndrome With Primary Pulmonary Hypertension - A Case Report

Ortner’s Syndrome or Cardio-vocal syndrome is a manifestation of hoarseness secondary to left recurrent laryngeal nerve (RLN) palsy with abnormal cardiovascular components. The association of pulmonary hypertension with Ortner’s Syndrome has not been widely available in the literature with very few cases reported worldwide.We present a case of a 17 years old lady with underlying Primary Pulmonary Hypertension, who presented with progressive hoarseness over the past 3 years associated with breathlessness and easy fatigue on exertion. Herein we discuss the options of treatment modality for Ortner’s Syndrome.

Prognostic Factors for Recovery from Left Recurrent Laryngeal Nerve Palsy After Minimally Invasive McKeown Esophagectomy: A Retrospective Study.

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. 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 6months. Univariate and multivariable logistic regression analyses were applied to evaluate the associations between different variables and the outcome of palsy. 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. 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.

Trajectory of Voice Rehabilitation in Ortner’s Syndrome: A Case Report

Ortner’s syndrome is characterized with hoarseness of voice due to left recurrent laryngeal nerve palsy and is primarily caused by cardiovascular disease. Based on the concurrent impairment of both the heart and voice, it is also described as Cardio-Vocal syndrome. Hoarseness and breathiness, are the core voice features of Ortner’s syndrome, occurring in children and adults alike. Formal and customized vocal rehabilitation using symptomatic voice therapy approach can elicit remarkable voice improvement in such cases. In this case study, a 28 years old female with such cardiac pathology and voice symptoms is documented. Vocal rehabilitation was initiated, after medical intervention. Normal voice characteristic was achieved within nine sessions of voice therapy as evident in pre and post therapy comparison of acoustic and perceptual parameters. This finding is imperative to the narratives of such rare cases, as it emphasizes on the early intervention. The results suggest that management plays a vital role in restoration of vocal characteristics in cases where otherwise there could have been a permanent damage. There are a few literatures on the voice profile of persons with Ortner’s syndrome however, no study, to the best of our exhaustive search, has been reported on vocal rehabilitation profile on Ortner’s syndrome. The present study explores the trajectory of voice recovery in Ortner’s syndrome.

Ortner's syndrome: A systematic review of presentation, diagnosis and management.

Ortner's syndrome (OS), also called cardiovocal syndrome, is a rare condition hallmarked by left recurrent laryngeal nerve palsy due to underlying cardiopulmonary disease. The purpose of this review is to systemically analyze the existing literature for cases of OS to outline typical presentation, methods of diagnosis, and management of these patients. Case reports, case series, and cohort studies describing OS between 1955 and 2021 were identified. Individual manuscripts were reviewed for clinical features, presentation, and management. A total of 117 patient cases were gathered from 92 published articles. Common symptoms included hoarseness, dyspnea, cough, and dysphagia. The most common associated comorbidity was aortic aneurysm (41%), followed by pulmonary hypertension (35%), mitral stenosis (17%), and hypertension (12%). Among those who were managed via surgical intervention, 85.4% reported improvement in their hoarseness. While historically OS was associated with mitral stenosis, in recent decades, aortic aneurysms and dilation of the pulmonary artery from pulmonary hypertension have emerged as primary etiologies of OS. Therefore, OS should be considered in any patient presenting with hoarseness and history of cardiopulmonary disease. Surgical intervention in appropriate candidates resolves OS in most cases.

436. USEFULNESS OF INTRAOPERATIVE CONTINUOUS NERVE MONITORING IN TRANSMEDIASTINAL MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Introduction We have previously reported that continuous intraoperative nerve monitoring (CIONM) is useful in reducing postoperative left recurrent laryngeal nerve paralysis (RLNP) in transmediastinal esophagectomy (TME). In this study, we investigated the relationship between the paralysis risk types on CIONM and postoperative RLNP. Methods A total of 161 patients who underwent TME for esophageal malignancies and esophagogastric junctional cancer with CIONM between October 2017 and July 2022. The relationship between clinical background factors, changes in amplitude during surgery, and left RLNP (endoscopic vocal cord findings on postoperative day 7) was retrospectively investigated. Furthermore, the relationship between LOS types (segmental or diffuse) and left RLNP was examined. Results The median age was 70 years, with 127 male and 34 female patients. At the end of transcervical procedure, 46 patients had amplitude less than 100 μV (LOS: loss of signal) and 78 patients had amplitude ≤50% of baseline. Postoperatively, 76.1% of LOS cases and 46.2% of cases with amplitudes ≤50% of baseline had left RLNP. The amplitude reduction types (LOS, baseline≤50%), primary tumor in the cervical/upper thoracic/middle thoracic esophagus, and males were significantly associated with left RLNP (p &amp;lt; 0.001). When examined by LOS type, RLNP was more common in segmental LOS than in diffuse LOS. Conclusion The pattern of amplitude reduction on CIONM is useful in predicting postoperative left RLNP. We will continue to increase the number of cases and verify the further effectiveness of CIONM for TME.

Improvement Effect of Upper Mediastinal Lymphadenectomy During Minimally Invasive Esophagectomy on the Prognosis in Squamous Cell Carcinoma: Efficacy Index and Propensity Score Matching Analyses.

The effect of lymphadenectomy around the recurrent laryngeal nerve (RLN) in open esophagectomy has been demonstrated with the efficacy index (EI). However, it remains unclear whether this effect exists for minimally invasive esophagectomy (MIE) in the prone position. The purpose of this study was to clarify whether the upper mediastinal lymphadenectomy contributed to improved prognosis in patients with esophageal squamous cell carcinoma. This study included 339 patients with esophageal squamous cell carcinoma treated with MIE in the prone position at Kobe University or Hyogo Cancer Center, Japan, from 2010 to 2015. EIs for each station, correlations between metastatic lymph nodes around the left RLN and RLN palsy, and survival of patients with and without upper mediastinal lymphadenectomy were investigated. Among 297 patients treated with upper mediastinal lymphadenectomy, Clavien- Dindo grade ≥ II left RLN palsy occurred in 59 patients (20%). Overall, EIs for the right RLN (7.4) and left RLN (6.6) were higher than EIs for other stations. For patients with upper-third or middle-third tumors, the trend was stronger. Left RLN palsy was more likely in patients with metastatic lymph nodes around the left RLN than in those without (44% vs 15%, p < 0.0001). After propensity score-matching, 42 patients were included in each group with and without upper mediastinal lymphadenectomy. In survival analyses, the 5-year overall survival rates were 55% vs 35% and cause-specific survival rates were 61% vs 43% for the patients with and without upper mediastinal lymphadenectomy respectively. Significant differences were confirmed in survival curves (overall survival: p = 0.03; cause-specific survival: p = 0.04, respectively). Upper mediastinal lymphadenectomy contributes to improved prognosis with high EIs in MIE in the prone position.

Ortner’s syndrome secondary to thoracic aortic aneurysm: a case series

BackgroundOrtner’s syndrome refers to vocal cord paralysis resulting from compression of the left recurrent laryngeal nerve by abnormal mediastinal vascular structures. This retrospective case series details our experience with Ortner’s syndrome due to thoracic aortic aneurysm.MethodsThis study was a retrospective analysis of a case series. A total of 4 patients (mean age, 65.5 years) with Ortner’s syndrome due to thoracic aortic aneurysm underwent thoracic endovascular aortic repair from July 2014 to May 2020. The patients’ demographics, comorbidities, initial symptoms, time from hoarseness to treatment, aneurysm shape and size, surgical procedures and outcome are summarized.ResultsA total of 4 patients with Ortner’s syndrome due to thoracic aortic aneurysm were analyzed. All the patients underwent thoracic endovascular aortic repair with no complications during the hospitalization period. At a mean follow-up of 26.8 (8–77) months, hoarseness in 3 patients had completely resolved or improved, and the symptoms in 1 patient had not progressed.ConclusionsHoarseness due to left recurrent laryngeal nerve palsy can be the presenting symptom of thoracic aortic aneurysm. Early diagnosis leads to timely treatment of these patients which may be helpful in the functional recovery of symptoms.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

180. SINGLE-PORT MEDIASTINOSCOPIC LYMPHADENECTOMY IN THE UPPER AND MIDDLE MEDIASTINUM USING CONTINUOUS INTRAOPERATIVE NERVE MONITORING

Abstract The left cervical approach with single-port mediastinoscopy is essential for radical esophagectomy without thoracotomy for esophageal cancer, which provides excellent visibility and handling along the esophagus to achieve radical lymph nodes (LNs) dissection in the upper and middle mediastinum. However, the transcervical procedure dissecting along the recurrent laryngeal nerve (RLN) requires careful use of both energy device for dissection and forceps for surgical field expansion to minimize the risk of RLN palsy. Using the left cervical approach, the LNs along the left RLN and tracheal bifurcation (subcarinal and bilateral main bronchial LNs) were dissected en bloc with the esophagus. The LNs along the right RLN were basically dissected through a right cervical incision under direct vision or dissected with the left cervical approach if visible. Intraoperative nerve monitoring (IONM) with NIM Response 3.0 was introduced to minimize the risk of RLN palsy. Continuous and intermittent IONMswere used for the left and right cervical procedures, respectively. Until March 2019, 175 patients underwent transmediastinal esophagectomy. Squamous cell carcinoma was predominant (93.7%). The upper and middle thoracic tumors were the most frequent (65.7%). Since IONM introduction, RLN palsy (grade I or more, CD classification) was significantly reduced. Without IONM (n = 106), the left RLN palsy was observed in 35.9%, while was in 13.6% with IONM (n = 66). In addition, the bilateral RLNs palsy was 14.2% without IONM, while was reduced to 3.0% with IONM. IONM is useful to reduce RLN palsy in transmediastinal esophagectomy. Especially, continuous IONM, which provides a real-time information on the risk procedure of RLN injury, is effective in preventing RLN palsy. The left cervical procedure with continuous IONM will be shown in movie.

A rare case of cervical sympathetic schwannoma

&lt;p&gt;Schwannomas are benign neoplasms arising from myelinating Schwann cells. Nerve sheath tumours arising from the sympathetic chain are very sporadic, with very few cases reported that presented with Horner’s syndrome. The authors describe its radiological and histological features and surgical management in this case report. A sixty-eight-year-old man presented with throat discomfort and hoarseness of voice for three months. He had a palpable mass on the left side in the submandibular region on neck examination. The patient had left recurrent laryngeal nerve palsy and Horner’s syndrome on general examination. MRI with contrast was performed to see the extent of the tumour. Exploratory cervicotomy was performed; the tumour was seen originating from the lower cervical sympathetic chain posterior to the carotid sheath. Histopathological examination confirmed the diagnosis of cervical sympathetic schwannoma. Cervical sympathetic schwannoma is a benign, slow-growing neoplasm with varied presentation. Presentation with Horner’s syndrome is a rare but reported presentation. Radiological imaging plays a vital role in the identification and surgical management. For symptomatic tumours, exploratory cervicotomy is the preferred approach for its wide exposure. Histopathological examination is confirmatory for the diagnosis.&lt;/p&gt;

Successful Surgical Repair of Type A Acute Aortic Dissection in a Patient with Vascular Ehlers-Danlos Syndrome.

Surgery for vascular complications of a patient with vascular Ehlers–Danlos syndrome (vEDS) is challenging due to the fragility of the associated tissues. In this study, we present a type A acute aortic dissection case in a patient with vEDS successfully treated via total arch replacement. A 42-year-old woman was transferred to our hospital 10 days after the onset of symptoms and underwent emergency surgery. Intraoperative findings revealed severe inflammatory changes without tissue fragility that is distinctive of vEDS. The postoperative course was uneventful except for left recurrent laryngeal nerve palsy, and 24 months after the operation, the patient has remained free from any arterial event.

Hoarseness in an older adult: Ortner syndrome.

A detailed examination in an older adult presenting with chronic hoarseness is mandatory to exclude an upper aerodigestive tract malignancy. We describe a 71-year-old chronic smoker with essential hypertension who presented with hoarseness and vocal fatigue for 5 months. Laryngoscopic examination showed left vocal fold paralysis with phonation gap. No growth was seen at all laryngeal and hypopharyngeal subsites. The rest of the head and neck, chest, upper limbs and neurovascular examination were unremarkable. A plain chest radiograph demonstrated a cause for the left recurrent laryngeal nerve palsy. The diagnosis, complications and definitive management of the underlying cause and resultant voice problem will be discussed.

HOARSE VOICE OF A FAILING HEART: CARDIO-VOCAL SYNDROME

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: A cardiopulmonary etiology of hoarseness of voice (HOV) is extremely uncommon. Here we describe a 71-year-old-male presenting with HOV due to an extremely enlarged Left Atrium (LA) that compressed the Left recurrent laryngeal nerve (LRLN). CASE PRESENTATION: A 71-year-old male with end stage renal disease and coronary artery disease presented with HOV and dyspnea of 8-month duration. He was seen at an otolaryngology clinic in the past and was diagnosed with left true vocal cord paralysis, however the etiology remained unclear. Family and social history were non-contributory. On physical exam, patient had a raspy HOV with conversational dyspnea. Also, he had a diastolic murmur, jugular venous distension, bibasilar rales and bilateral pitting edema in the lower extremities. Extensive laboratory work-up was negative except an elevated brain natriuretic peptide of 960 pg/ml, Creatinine 4.5 mg/dl and GFR 12 ml/min.Echocardiogram revealed ejection fraction of 25% with severe mitral stenosis and pronounced LA diameter of 7.9 cm [Figure1]. Indirect laryngoscopy demonstrated true left vocal cord paralysis [Figure 2]. A non-contrast computed tomography (CT) scan of the neck, chest and head did not reveal any relatable etiologies for hoarseness. With the findings on indirect laryngoscopy coupled with the echocardiographic findings, it was postulated that the patient's HOV was due to compression of the left recurrent laryngeal nerve from an enlarged LA and the diagnosis of Ortner's Syndrome was established. The patient was later discharged with guideline directed medical therapy for heart failure. During subsequent follow up visits the patient continued to have hoarseness and eventually expired due to decompensated heart failure. DISCUSSION: Cardio-vocal syndrome (CVS) is a rare condition in which the cardio-thoracic structures, classically an enlarged Left Atrium (LA), impinges on the left recurrent laryngeal nerve (LRLN) resulting in hoarseness of voice [2]. While Injury to the LRLN secondary to neck surgeries and extra-laryngeal malignancy are the most common cause of neurological voice change [3], multiple cardio-thoracic disorders causing LRLN palsy are described in the literature. LAE accounts for approximately 0.6-5% of all cases of CVS. It is a diagnosis of exclusion and can be supported by echocardiographic and CT findings. Unfortunately, there is no concrete medical treatment available for HOV due to LAE. In those with mitral stenosis accounting for LAE, mitral valve replacement is often curative. In our case, due to advanced age and significant morbidity burden, the patient was reluctant to pursue any surgical intervention which unfortunately led to persistent HOV and lethal outcome. CONCLUSIONS: A Cardio-thoracic etiology of HOV is rare. Clinicians should be aware of this possibility as it could aid in early recognition of silent cardiac disease and also identify a rare cause of HOV. REFERENCE #1: Subramaniam, V., Herle TV, A., Mohammed, N., & Thahir, M. (2011). Ortner's syndrome: case series and literature review. Brazilian journal of otorhinolaryngology, 77(5), 559-562. REFERENCE #2: Khan, I. A., Wattanasauwan, N., & Ansari, A. W. (1999). Painless aortic dissection presenting as hoarseness of voice: cardiovocal syndrome: Ortner's syndrome. The American journal of emergency medicine, 17(4), 361-363. REFERENCE #3: Plastiras, S. C., Pamboucas, C., Zafiriou, T., Lazaris, N., & Toumanidis, S. (2010). Ortner's syndrome: a multifactorial cardiovocal syndrome. Clinical cardiology, 33(6), E99. DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Sonia Dogra, source=Web Response No relevant relationships by Jeff Manfredonia, source=Web Response No relevant relationships by Niravkumar Patel, source=Web Response No relevant relationships by Leticia Peltzer, source=Web Response No relevant relationships by Dakota Robertson, source=Web Response

Incidence of Recurrent Laryngeal Nerve Palsy in Robot-Assisted Versus Conventional Minimally Invasive McKeown Esophagectomy in Prone Position: A Propensity Score-Matched Study.

Esophagectomy with lymphadenectomy is the principal treatment for localized esophageal cancer. Conventional minimally invasive esophagectomy (C-MIE) in prone position has spread worldwide as it is less invasive. However, its efficacy remains controversial. Robot-assisted MIE (RAMIE) can have more advantages than C-MIE. Therefore, the current study aimed to validate whether RAMIE is associated with lower incidence of left recurrent laryngeal nerve (RLN) palsy compared with C-MIE in prone position. In total, 404 patients with esophageal carcinoma underwent MIE (353 C-MIEs and 51 RAMIEs) in prone position at Kobe University between 2010 and 2020. Then, propensity score matching was performed, and results showed that 51 patients should be included in each group. Thereafter, the perioperative outcomes between the two groups were compared. The RAMIE group had a significantly longer operative time than the C-MIE group (P<0.0001). However, the number of lymph nodes resected along the left RLN was similar in both groups. Moreover, the incidence of left RLN palsy was significantly lower in the RAMIE group than in the C-MIE [Clavien-Dindo classification grade II; 0 (0%) versus 32 (9%), P=0.022 in entire cohort, and 0 (0%) versus 5 (10%), P=0.022 in matched cohort. Esophagectomy Complications Consensus Group definitions type I; 8 (16%) versus 101 (29%), P=0.041 in entire cohort and 8 (16%) versus 18 (35%) in matched cohort, P=0.023]. RAMIE is superior to C-MIE in prone position in decreasing the incidence of left RLN palsy.

Novel "Modified Bascule Method" for Lymphadenectomy Along the Left Recurrent Laryngeal Nerve During Robot-Assisted Minimally Invasive Esophagectomy.

Given the worldwide popularization of conventional minimally invasive esophagectomy (C-MIE), robot-assisted MIE (RAMIE) can be expected to provide a finer procedure. However, controversy remains regarding whether RAMIE is superior to C-MIE in preventing recurrent laryngeal nerve (RLN) palsy. Considering the shallow learning curve for RAMIE, a novel procedure for lymphadenectomy along the RLN during RAMIE is needed. Based on a logical and simple understanding of the left upper mediastinum anatomy, the authors developed a novel "modified bascule method" for RAMIE that could simplify lymphadenectomy along the left RLN and prevent it from being touched and stretched. Between 2018 and 2020, 46 patients with esophageal carcinoma underwent RAMIE using this method at Kobe University. The modified bascule method was used to perform RAMIE for 29 men and 17 women with a median age of 67 years (range, 49-82 years). The median thoracoscopic procedure time was 438 min (range, 344-625 min), and the median console time was 351 min (range 273-518 min). The study harvested a median of 24 (range, 8-34) lymph nodes from the thoracic portion and 4 (range, 0-10) lymph nodes from along the left RLN. The mortality rate was 0%. Postoperative left RLN palsy classified as Clavien-Dindo (C-D) grade 1 or higher was observed for 9 patients (19%), whereas grade 2 or higher was not seen (0%). Pneumonia and anastomotic leakage rates higher than C-D grade 2 were respectively 13% and 19%. The novel modified bascule method for RAMIE can promote feasible lymphadenectomy along the left RLN even when performed during the learning period.

A standardized procedure for upper mediastinal lymph node dissection improves the safety and efficacy of robotic McKeown oesophagectomy.

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 who received robotic McKeown oesophagectomy for cancer were divided into two groups (pre and poststandardisation). Perioperative outcomes were retrospectively compared. 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. 131min, respectively, p<0.001). Our standardised surgical approach is efficient and may increase the safety of UMLND.