Recurrent Laryngeal Nerve Lymph Node Dissection Research Articles

150. PATTERN OF LYMPH NODE RECURRENCE AFTER NEOADJUVANT CHEMORADIOTHERAPY AND MODIFIED EN BLOC ESOPHAGECTOMY

Abstract Background Esophageal cancer is an aggressive malignancy with high incidence of lymph node metastasis and recurrence rate even after neoadjuvant treatment and radical resection. Previous study has shown that modified en bloc esophagectomy (mEBE) improves survival for esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (nCRT). In this study, we aim to investigate the pattern of lymph node recurrence after nCRT+mEBE. Methods The data of patients who received nCRT followed by curative surgical resection for ESCC were retrospectively reviewed. The mEBE includes ‘mesophagus’ dissection and bilateral recurrent laryngeal nerve node dissection, whereas conventional esophagectomy (CE) only requires periesophageal tissues dissection that were close to the esophagus. The pattern of recurrence, especially lymph node recurrence (cervical, upper mediastinum, infra-carina, and abdominal), were compared between CE and mEBE, with stratification according to pathological stage (ypT0N0 or not.) Results A total of 221 (CE, n = 181; mEBE, n = 40) patients were included. Mediastinal lymph node recurrence was noted in 16.0% and 7.5% of patients after CE and mEBE, respectively (p = 0.166). In ypT0N0 patients who received CE, 6.0% had upper mediastinum recurrence, whereas no mediastinal recurrence was noted after mEBE (p = 0.329). In non-ypT0N0 stage patients who received CE, 15.3% and 8.2% had upper mediastinum and infra-carina recurrences, compared to 12.0% and 0% after mEBE (p = 0.283). There cervical/abdominal recurrences were noted in 6.6%/7.2% and 15.0%/5.0% after CE and mEBE, respectively (p = 0.080/0.618). Conclusion Although there was no significant difference in lymph node recurrence pattern between mEBE and CE, we observed that (1) 6% of ypT0N0 patients developed mediastinal lymph node recurrence after CE, implying the possibility of understaging after CE; (2) no patients developed infra-carina lymph node recurrence after mEBE, suggesting the necessity of mesoesophagus dissection, and (3) high incidence of cervical lymph node recurrence even after mEBE, indicating that cervical dissection should be considered in selected patients.

Initial experience with modified en bloc robot-assisted minimally invasive oesophagectomy for thoracic oesophageal squamous cell carcinoma.

The feasibility and safety of en bloc robot-assisted minimally invasive oesophagectomy (RAMIE) need to be verified. Forty-seven patients who received conventional RAMIE and 31 who received modified en bloc RAMIE at Henan Cancer Hospital were included in the study cohort. We compared the perioperative outcomes of conventional RAMIE and modified en bloc RAMIE. Compared with the conventional RAMIE group, the en bloc RAMIE group yielded a higher total number of lymph nodes (p=0.001), especially thoracic lymph nodes (p=0.025) and left recurrent laryngeal nerve (RLN) lymph nodes (p=0.005). No notable differences were found in the rate of total complications (p=0.663) or RLN injury (p=0.891) between the two groups. The preoperative and postoperative serological indicators were comparable between the two groups. Modified en bloc RAMIE was safe and feasible for patients with oesophageal squamous cell carcinoma and improved lymph node dissection, especially thoracic and left RLN lymph node dissection.

Perioperative Outcomes and Learning Curve of Robot-Assisted McKeown Esophagectomy

BackgroundThis study aimed to evaluate the perioperative outcomes of patients undergoing robot-assisted McKeown esophagectomy (RAME) and the learning curves of surgeons performing RAME at a single center. MethodsPerioperative outcomes of RAME and video-assisted McKeown esophagectomy (VAME) were compared after eliminating confounding factors by propensity score matching (PSM). The cumulative sum (CUSUM) method was used to evaluate the learning curves of RAME for a single surgical team. ResultsIn general, a total of 198 patients with esophageal cancer (RAME: 45 patients, VAME: 153 patients) were included in this study, and 43 pairs of patients receiving RAME or VAME were matched using 1:1 PSM analysis. Those in the RAME group had more lymph nodes dissected in the total lymph nodes (median 29.0 vs. 26.0, P = 0.011) and the upper mediastinum (median 8.0 vs. 6.0, P < 0.001), especially the left recurrent laryngeal nerve (RLN) lymph node (median 4.0 vs. 2.0, P = 0.001). According to the trend of the CUSUM plot, the learning curve was divided into two stages at the 20th RAME procedure. After mastering the learning curve, RAME harvested a significantly higher number of upper mediastinal lymph nodes (median 9.0 vs. 6.0, P = 0.001), left RLN lymph nodes (median 5.0 vs. 3.5, P = 0.003), and right RLN lymph nodes (median 4.0 vs. 2.0, P = 0.002). Meanwhile, the incidence of postoperative pneumonia in the proficiency phase was significantly lower than that in the learning phase (4.0% vs. 25.0%, P = 0.04). ConclusionsRAME improved left RLN lymph node dissection. Surgeons with extensive VAME experience need at least 20 cases to achieve early proficiency in RAME.

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.

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.

Clinical value of lymph node dissection for stage T1b mid-thoracic esophageal squamous cell carcinoma

Surgery remains the mainstay of treatment for esophageal squamous cell carcinoma (ESCC), during which lymph node (LN) dissection, especially recurrent laryngeal nerve (RLN) LN dissection, is particularly important and challenging. This study aimed to investigate the LN metastasis of stage T1b mid-thoracic ESCC and explore the clinical value of RLN LN dissection. The clinicopathological data of 254 patients with stage T1b mid-thoracic ESCC who underwent the McKeown procedure ("tri-incisional esophagectomy") and three-field LN dissection (3FD) at Fujian Cancer Hospital from January 2010 to December 2015 were retrospectively analyzed. The value of LN dissection (especially RLN LNs) was evaluated by calculating the metastasis rate of each LN station. The efficacy index (EI) of the dissection was calculated by multiplying the frequency (%) of metastases to a station and the 5-year survival rate (%) of patients with metastases to that station, and then dividing by 100. The stage T1b mid-thoracic ESCC had the highest rate of metastasis in the paracardiac LNs (4.3%), followed by RLN LNs (2.8%) and the left gastric artery LNs (2.8%). The 5-year survival rate was highest in patients who received lesser gastric curvature LN dissection (100%), followed by patients who underwent right RLN LN dissection (80%), and was 50% in patients who had undergone dissection of the left RLN LNs, upper paraesophageal LNs, subcarinal LNs, and left gastric artery LNs, respectively. In addition, dissection of the right RLN LNs had the highest EI value (2.2), followed by the dissection of LNs along the lesser curvature of the stomach (1.6) and left gastric artery LNs (1.4). Right RLN LNs have a metastasis rate only lower than that of the paracardiac LNs, but could be the most valuable location for performing dissection.

Endobronchial Ultrasound Improves Evaluation of Recurrent Laryngeal Nerve Lymph Nodes in Esophageal Squamous Cell Carcinoma Patients.

The bilateral recurrent laryngeal nerve (RLN) lymph nodes are the most common metastatic site for esophageal squamous cell carcinoma (ESCC); however, the RLNs are susceptible to injury during dissection. Clinically, there is an urgent need to determine an effective diagnostic method for RLN nodes to help achieve selective nodal dissection and avoid potential serious complications by performing more conservative surgery for those with nonmetastatic nodes. Here, we innovatively applied endobronchial ultrasonography (EBUS) and investigated its diagnostic performance for preoperative evaluation of RLN nodes in ESCC patients. All 81 enrolled ESCC patients underwent preoperative EBUS and CT examinations. The ability of EBUS and CT to detect RLN node metastasis was evaluated based on the resulting sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV). The diagnostic performance of EBUS was superior to that of CT; in particular, EBUS of the left RLN (L-RLN) nodes presented the best sensitivity, specificity, PPV, NPV, and accuracy compared with EBUS evaluations of the right RLN (R-RLN) nodes, CT of the L-RLN and R-RLN nodes. Moreover, EBUS combined with CT increased the NPV relative to that of EBUS or CT alone, promoting the ability to identify true-negative RLN nodes. In particular, the NPVs of the combined modality were 100% for both the L- and R-RLN nodes in early-T-stage (T1-T2) ESCC. EBUS is an efficient tool for RLN node evaluation, and the combination with CT may provide better guidance for selective RLN node dissection in ESCC patients.

Safety and oncological efficacy of bilateral recurrent laryngeal nerve lymph-node dissection after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma: a propensity-matched analysis.

BackgroundWe 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).MethodsWe 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).ResultsNo 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.ConclusionsRLN 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.Electronic supplementary materialThe online version of this article (10.1007/s10388-019-00688-7) contains supplementary material, which is available to authorized users.

Transition from video-assisted thoracoscopic to robotic esophagectomy: a single surgeon's experience.

Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P<0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P=0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P=0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.

PS01.223: ‘ENERGY-LESS TECHNIQUE’ WITH MINI-CLIPS FOR RECURRENT LARYNGEAL NERVE LYMPH NODE DISSECTION IN PRONE THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Esophagectomy with radical mediastinal lymph node dissection remains the standard option for the curative treatment of esophageal squamous cell carcinoma. However, meticulous lymph node dissection along the recurrent laryngeal nerve (RLN), often results in recurrent laryngeal nerve paralysis (RLNP), leading to postoperative laryngopharyngeal dysfunction. Recently, thoracoscopic radical esophagectomy has been performed as a minimally invasive surgery for esophageal cancer. Although thoracoscopic surgery appears to reduce the risk of postoperative pulmonary complications and permits earlier postoperative recovery, the issue of postoperative RLNP remains unresolved. Methods We 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. Then we introduced the use of mini-clips for hemostasis before cutting the vessels with scissors. In this study, we analyzed data from 64 patients with esophageal cancer who underwent thoracoscopic esophagectomy in prone position. The patients were divided into two groups according to the period of operation: before and after the introduction of energy-less techniques with mini-clips. Surgical results were compared between the 2 groups. Results With regard to RLNP, the incidence was 24.0% in the before group; this incidence went down to 5.1% in the after group, after the introduction of energy-less techniques with mini-clips (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). There were two operators performing thoracoscopic esophagectomy at our institution: surgeon A, a senior doctor with a 22-year career; and surgeon B, a junior doctor with a 12-year career. We compared all surgical results and found that there were no differences between the two doctors. Conclusion Our energy-less technique with mini-clips in RLN lymph node dissection could keep the surgical field dry by preventing minor bleeding. This contributed both to prevent RLNP and to shorten the patient's hospital stay. This technique was also considered useful for standardizing procedures within our institution, because special skills were not needed. Disclosure All authors have declared no conflicts of interest.

Diagnostic value of intraoperative ultrasonography in assessing thoracic recurrent laryngeal nerve lymph nodes in patients with esophageal cancer

BackgroudThe incidence of recurrent laryngeal nerve (RLN) injury has increased due to RLN lymph node dissection. The aim of this study was to evaluate the ability of intraoperative ultrasonography (IU) to detect RLN nodal metastases in esophageal cancer patients.MethodsSixty patients with esophageal cancer underwent IU, computed tomography (CT), and endoscopic ultrasonography (EUS) to assess for RLN nodal metastasis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared.ResultsThe sensitivities of IU, CT, and EUS in diagnosing right RLN nodal metastases were 71.4, 14.3, and 30.0%, respectively, and a significant difference among these three examinations was observed (χ2 = 10.077, P = .006). The specificities of IU, CT, and EUS for diagnosing right RLN nodal metastasis were 67.4, 97.8, and 95.0%, respectively, and a significant difference was observed (χ2 = 21.725, P < .001). No significant differences in either PPV or NPV were observed when diagnosing right RLN nodal metastases. For diagnosis of left RLN lymph nodal metastases, the sensitivities of IU, CT, and EUS were 91.7, 16.7, and 40.0% respectively. There was a significant difference among these diagnostic sensitivities (χ2 = 14.067, P = .001). The specificities of IU, CT, and EUS for diagnosis of left RLN nodal metastases were 79.2, 100, and 82.5%, respectively and a significant difference was observed (χ2 = 10.819, P = .004). No significant differences were observed in PPV or NPV for these examinations when diagnosing left RLN nodal metastases.ConclusionIntraoperative ultrasonography showed superior sensitivity compared with preoperative CT or EUS in detecting RLN lymph node metastasis in patients with thoracic esophageal cancer.

Erratum: Learning curve for robotic esophagectomy and dissection of bilateral recurrent laryngeal nerve nodes for esophageal cancer.

Dissection of bilateral recurrent laryngeal nerve (RLN) nodes is a technically demanding procedure, but robotic systems have been useful for RLN node dissection. This retrospective study investigated the learning curve for bilateral RLN node dissection in esophageal-cancer patients using a robotic system for esophageal cancer. We retrospectively reviewed 33 consecutive patients who received a robotic esophagectomy and total lymphadenectomy by single surgeon. The patients were divided into either group 1 (initial 20 cases) or group 2 (later 13 cases). The mean patient age was 61.88 ± 9.03 years and 28 (84.8%) patients were male. Most cases were pathologically diagnosed as squamous cell carcinoma. The lesion locations included 3 (9.1%) in the upper esophagus, 12 (63.6%) in the mid esophagus, and 9 (27.3%) in the lower esophagus. Eleven (33.3%) cases were stage I, 7 (21.2%) were stage II, and 15 (45.5%) were stage III. One case in group 2 (3%) suffered operative mortality. Operation time, robot console time, and blood loss were similar between the two groups. The timing of right and left RLN node dissection, the number of total dissected lymph nodes, and the percentage of dissected right and left RLN nodes were also comparable. However, the incidence of vocal cord palsy was significantly lower in group 2 (55% vs. 0%, p= 0.02). The incidence of other operative complications did not vary between the two groups. Even though operative outcomes and incidence of other complications were comparable between the two groups, the incidence of vocal cord palsy decreased significantly after 20 cases. Thus, we conclude that a minimum of 20 cases is required before a surgeon is experienced enough to perform safe dissection of bilateral RLN nodes.

Lymph node dissection along the recurrent laryngeal nerves in patients with oesophageal cancer who had undergone chemoradiotherapy: is it safe?

Upper mediastinal lymph node dissection (LND)-especially along the recurrent laryngeal nerve (RN)-is the most challenging part of oesophageal cancer surgery. We investigated whether thoracoscopic RN LND may be safely performed in patients with oesophageal cancer who had undergone chemoradiotherapy (CRT). Patients with oesophageal cancer who had undergone thoracoscopic RN LND (n = 103) were divided into 2 groups according to whether they had prior treatment with CRT or not [the CRT group (n = 65) vs the upfront surgery group (n = 38), respectively]. All patients were operated on by a single surgeon. Intergroup comparisons were made in terms of (i) the number of dissected nodes, (ii) rates of RN palsy and (iii) rates of perioperative complications. The learning curve for the RN LND procedure was investigated using the cumulative sum method. RN LND after CRT was more technically challenging when performed in the left side. Complete skeletonization of the left RN was achieved only in 66.2% of patients in the CRT group (vs 86.8% in the upfront surgery group; P = 0.022). The rate of postoperative left side RN palsy was significantly higher in the CRT group (26.6%) than in the upfront surgery group (7.9%, P = 0.022), albeit resulting in neither higher pneumonia rates nor longer hospital stays. The cumulative sum analysis revealed a steep learning curve for left RN LND in the CRT group. Unfortunately, an acceptable proficiency (left RN palsy rate: 15%) was not achievable even after treatment in 65 cases. Thoracoscopic RN LND is safe but poses significant challenges in CRT-treated patients.

Cervicothoracoscopic Approach in Esophagectomy.

Esophageal cancer frequently metastasizes to lymph nodes along the recurrent laryngeal nerve (RLN).1 Therefore, it is essential to dissect RLN nodes for curative esophagectomy. Complete RLN node dissection without injury to the organs at the cervicothoracic junction requires experienced techniques. This report describes the cervicothoracoscopic approach, whereby the complete dissection can be safely performed. With this approach, both cervical and laparoscopic procedures are performed in the open-leg supine position before the thoracoscopic procedure is performed in the prone position. For RLN node dissection, the paratracheal lymphatic chain is detached from RLNs at the cervicothoracic junction in the cervical operation field, and the detached tissue is retrieved together with the mediastinal RLN lymph nodes via thoracoscopy. This approach was applied to all squamous cell carcinoma patients and to patients with Siewert type 1 tumors of stage 2 or more, except for patients with clinically suspected T4 tumors. Of 91 patients, 27 (29.7%) experienced RLN palsy and 15 (16.5%) experienced postoperative pneumonia. Hoarseness due to RLN palsy was improved in almost all the patients within 6 postoperative months, and persistent paralysis was seldom observed. Within 30 days, neither a reoperation nor a hospital mortality occurred. The cervicothoracoscopic approach enables complete en bloc dissection of the lymphatic chain that lies along RLN in the cervicothoracic junction. Also, with this approach, RLNs can be identified easily because RLNs are already exposed at the upper mediastinum by the cervical procedure. Therefore, this approach may contribute to improving the surgical curability and preventing RLN injury.

Learning curve for robotic esophagectomy and dissection of bilateral recurrent laryngeal nerve nodes for esophageal cancer.

Dissection of bilateral recurrent laryngeal nerve (RLN) nodes is a technically demanding procedure, but robotic systems have been useful for RLN node dissection. This retrospective study investigated the learning curve for bilateral RLN node dissection in esophageal-cancer patients using a robotic system for esophageal cancer. We retrospectively reviewed 33 consecutive patients who received a robotic esophagectomy and total lymphadenectomy by single surgeon. The patients were divided into either group 1 (initial 20 cases) or group 2 (later 13 cases). The mean patient age was 61.88±9.03 years and 28 (84.8%) patients were male. Most cases were pathologically diagnosed as squamous cell carcinoma. The lesion locations included 3 (9.1%) in the upper esophagus, 12 (63.6%) in the mid esophagus, and 9 (27.3%) in the lower esophagus. Eleven (33.3%) cases were stage I, 7 (21.2%) were stage II, and 15 (45.5%) were stage III. One case in group 2 (3%) suffered operative mortality. Operation time, robot console time, and blood loss were similar between the two groups. The timing of right and left RLN node dissection, the number of total dissected lymph nodes, and the percentage of dissected right and left RLN nodes were also comparable. However, the incidence of vocal cord palsy was significantly lower in group 2 (55% vs. 0%, p=0.02). The incidence of other operative complications did not vary between the two groups. Even though operative outcomes and incidence of other complications were comparable between the two groups, the incidence of vocal cord palsy decreased significantly after 20 cases. Thus, we conclude that a minimum of 20 cases is required before a surgeon is experienced enough to perform safe dissection of bilateral RLN nodes.

Lymph Node Evaluation in Robot-Assisted Versus Video-Assisted Thoracoscopic Esophagectomy for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis.

Radical lymph node dissection (LND) along the bilateral recurrent laryngeal nerve (RLN) is a surgically challenging procedure with a high rate of morbidity. Here, we assessed in a retrospective manner the adequacy of LND along the RLN performed with robot-assisted thoracoscopic esophagectomy (RATE) versus video-assisted thoracoscopic esophagectomy (VATE) in patients with esophageal squamous cell carcinoma (ESCC). This was a single-center, retrospective, propensity-matched study. ESCC patients who underwent McKeown esophagectomy and bilateral RLN LND with a minimally invasive approach were divided into two groups according to the use of robot-assisted surgery or not (RATE vs VATE, respectively). Using propensity score matching, 34 balanced matched pairs were identified. The number of dissected nodes as well as the rates of RLN palsy and perioperative complications served as the main outcome measures. No conversion to open thoracotomy occurred in either group. Intraoperative blood loss and the need of blood transfusions did not show significant intergroup differences. The mean number of dissected nodes was similar in the two study groups, the only exception being the left RLN area. Specifically, the mean number of nodes removed from this region was 5.32 in the RATE group and 3.38 in patients who received VATE (p=0.007). Notably, the RATE and VATE groups did not differ significantly with regard to rates of both RLN palsy (20.6 vs 29.4%, respectively, p=0.401) and pulmonary complications (5.9 vs 17.6%, respectively, p=0.259). Compared with VATE, RATE resulted in a higher lymph node yield along the left RLN without increasing morbidity.

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.