Recurrent Laryngeal Nerve Lymph Node Research Articles

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

A novel web-based dynamic nomogram for recurrent laryngeal nerve lymph node metastasis in esophageal squamous cell carcinoma.

BackgroundPatients with esophageal squamous cell carcinoma (ESCC) are liable to develop recurrent laryngeal nerve (RLN) lymph node metastasis (LNM). We aimed to assess the predictive value of the long diameter (LD) and short diameter (SD) of RLN lymph node (LN) and construct a web-based dynamic nomogram for RLN LNM prediction.MethodsWe reviewed 186 ESCC patients who underwent RLN LN dissection from January 2016 to December 2018 in the Affiliated Hospital of North Sichuan Medical College. Risk factors for left and right RLN LNM were determined by univariate and multivariate analyses. A web-based dynamic nomogram was constructed by using logistic regression. The performance was assessed by the area under the curve (AUC) and Brier score. Models were internally validated by performing five-fold cross-validation.ResultsPatients who underwent left and right RLN LN dissection were categorized as left cohort (n = 132) and right cohort (n = 159), with RLN LNM rates of 15.9% (21/132) and 21.4% (34/159), respectively. The AUCs of the LD (SD) of RLN LN were 0.663 (0.688) in the left cohort and 0.696 (0.705) in the right cohort. The multivariate analysis showed that age, the SD of RLN LN, and clinical T stage were significant risk factors for left RLN LNM (all P < 0.05), while tumor location, the SD of RLN LN, and clinical T stage were significant risk factors for right RLN LNM (all P < 0.05). The dynamic nomograms showed reliable performance after five-fold cross-validation [(left (right), mean AUC: 0.814, range: 0.614–0.891 (0.775, range: 0.084–0.126); mean Brier score: 0.103, range: 0.084–0.126 (0.145, range: 0.105–0.206)], available at https://mpthtw.shinyapps.io/leftnomo/ and https://mpthtw.shinyapps.io/rightnomo/.ConclusionThe LD and SD of RLN LN are inadequate to predict RLN LNM accurately, but online dynamic nomograms by combined risk factors show better prediction performance and convenient clinical application.

Clinical Outcome of Intraoperative Recurrent Laryngeal Nerve Monitoring during Thoracoscopic Esophagectomy and Mediastinal Lymph Node Dissection for Esophageal Cancer.

Mediastinal lymph dissection in esophagectomy for patients with esophageal cancer is important. The dissection of recurrent laryngeal nerve (RLN) lymph nodes could cause RLN injury, vocal cord palsy, pneumonia, and respiratory failure. This retrospective study aimed to evaluate the effects of intraoperative RLN monitoring in esophagectomy and mediastinal lymph node dissection in preventing RLN injury and vocal cord palsy. This study included 75 patients who underwent minimally invasive esophagectomy and mediastinal lymph node dissection for esophageal cancer with (38 patients) and without (37 patients) IONM at Changhua Christian Hospital from 2015 to 2020. The surgical and clinical outcomes were reviewed. Patients in the IONM group had more advanced clinical T status, shorter operation time (570 vs. 633 min, p = 0.007), and less blood loss (100 mL vs. 150 mL, p = 0.019). The IONM group had significantly less postoperative vocal palsy (10.5% vs. 37.8%, p = 0.006) and pneumonia (13.2% vs. 37.8%, p = 0.014) than that in the non-IONM group. IONM was an independent factor for less postoperative vocal cord palsy that was related to postoperative 2-year survival. This study demonstrated that IONM could reduce the incidence of postoperative vocal cord palsy and pneumonia.

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

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

How to distinguish thoracic and cervical lymph nodes during minimally invasive esophagectomy.

PurposeIn this article, we aimed to reconstruct the cervical–thoracic junction plane (CTJP) using a three‐dimensional (3D) reconstruction system. Thus, the CTJP can be judged during surgery to better distinguish cervical–thoracic lymph nodes.MethodsWe included patients in Fujian Medical University Union Hospital from December 2019 to March 2020. All patients underwent a thin‐slice and enhanced computed tomography scan of the chest with 3D reconstruction using the IQQA system (EDDA technology) to reconstruct the CTJP, brachiocephalic trunk, right common carotid artery, and right subclavian artery. The distance from the intersection of the right subclavian artery and the CTJP to the origin of the right subclavian artery (ORSA) was measured, and the relationship between this distance and the patient's sex, BMI and height was analyzed.ResultsSeventy‐three patients were enrolled, of whom 12 had ORSA above the CTJP, while 61 had ORSA below the plane. There was a significant difference in age between the two groups (p = 0.04), compared with height, weight and BMI (p > 0.05). In 61 patients with the ORSA below the CTJP, the average distance was 24.7 ± 7.6 mm. The difference between the distance and BMI (p = 0.02) was statistically significant, and it was increased with increasing BMI.ConclusionsThe relationship between the ORSA and CTJP can be clarified through 3D reconstruction. The cervical‐thoracic recurrent laryngeal nerve lymph nodes can be distinguished clearly in minimally invasive esophagectomy, contributing to the accurate N staging of middle‐thoracic esophageal cancer.

Pattern and Predictive Factors of Metastasis in Lymph Nodes Posterior to the Right Recurrent Laryngeal Nerve in Papillary Thyroid Carcinoma.

ObjectiveThe right cervical central lymph nodes include lymph nodes anterior to the right recurrent laryngeal nerve (LN-arRLN) and lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN), and are separated by the right recurrent laryngeal nerve (RLN). LN-prRLN is a common site of nodal recurrence after the resection of papillary thyroid carcinoma (PTC). However, the complexity in anatomical structure brings difficulties in determining the surgical scope, so it is necessary to assess the pattern and predictive factors of right cervical central lymph nodes, especially LN-prRLN metastasis in papillary thyroid carcinoma.MethodsA total of 562 diagnosed PTC patients who underwent right or total thyroidectomy were enrolled in this retrospective study. The clinicopathological features were collected, univariate and multivariate analyses were performed to determine predictive factors of the right central lymph node metastasis.ResultsIn this study, the metastatic rates of the right CLN, the LN-arRLN and the LN-prRLN were 59.6% (335/562), 51.8% (291/562) and 30.4% (171/562), respectively. And 22.6% (127/562) of patients had both LN-arRLN and LN-prRLN metastasis. Among patients without LN-arRLN metastasis, the rate of LN-prRLN metastasis was 16.2% (44/271), accounting for 25.7% of the LN-prRLN metastasis group. Factors associated with an increased risk of LN-arRLN metastasis include male, age below 55 years, tumor size > 1cm, extrathyroidal extension (ETE), clinical lymph nodes metastasis(cN1), lateral lymph node metastasis, and left CLN metastasis. In addition, ETE, lateral lymph node metastasis, and LN-arRLN metastasis were independent factors of LN-prRLN metastasis. The predictive factors of LN-prRLN in cN0 PTC were further explored, revealing that tumor size ≥1.5cm, ETE, and LN-arRLN metastasis were independent predictors of LN-prRLN metastasis in cN0 PTC.ConclusionThe LN-prRLN should not be ignored in surgery because of its high rate of metastasis. Our findings indicate that thorough dissection of central lymph nodes, especially LN-prRLN is crucial in clinical work.

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.

198: ROBOTIC ASSISTED TRANS CERVICAL ESOPHAGECTOMY (RACE PROCEDURE): DESCRIPTION OF THE SURGICAL TECHNIQUE AND PRELIMINARY RESULTS

Abstract Background and aim A combined trans-hiatal and transcervical approach to perform esophagectomy has been described in the literature for patients who are not candidates for a transthoracic approach. In this context, the technical limitations of conventional laparoscopy might be overcome by the application of robotic systems such as the DaVinci Xi. We aimed at describing the technical details and the feasibility of our technique for the robotic-assisted trans-cervical esophagectomy (RACE) and a preliminary case series. Methods In the abdominal phase the DaVinci Xi is docked using the standard 5-trocar configuration used for Ivor-Lewis esophagectomy. After gastric mobilization, tubulization and D2 lymphadenectomy, the dissection is advanced trans-hiatally until the tracheal carina. Infra-tracheal lymph-node dissection is normally feasible from the abdomen. A left cervical incision and neck lymph node dissection are performed, the esophagus is encircled. The robot is docked at the neck using a gel port with a 3-trocar configuration and an assistant-trocar for suction. The upper mediastinal preparation starts by dissecting the esophagus from the mediastinal pleura bilaterally, the pars membranacea anteriorly and the aortic arch proceeding caudally. Dissection of the left recurrent laryngeal nerve (l-RLN) lymph nodes can be achieved; care should be taken to avoid nerve injuries. Proceeding caudally, the tracheal dissection is advanced to the left bronchus. The azygos vein is encountered at the right tracheobronchial angle. Dissection of bronchial lymph nodes is performed bilaterally, the plane is connected to the previous abdominal plane. After retrieval of the specimen an end-to-side circular stapled anastomosis is performed at the neck. Results The procedure was completed in 4 patients with mid-esophageal squamous cell carcinoma who were not candidate for a trans-thoracic approach due to cardio-pulmonary comorbidities. Median hospital stay was 14 (9–18) days, median ICU stay was 4 (1–6) days. Left vocal cord palsy requiring rehabilitation therapy occurred in 2 patients (50%). No postoperative mortality was recorded. R0 resection was achieved in all patients with a median of 19 (15–22) retrieved lymph nodes. Conclusion RACE using the robotic system is feasible and provides an adequate surgical radicality. The procedure is safe, although the rate of RLN injury is higher.

Development and validation of a nomogram for prediction of cervical lymph node metastasis in middle and lower thoracic esophageal squamous cell carcinoma

BackgroundEstimates of cervical lymph node (LN) metastasis in patients with middle and lower thoracic esophageal squamous cell carcinoma (ESCC) are important. A nomogram is a useful tool for individualized prediction.MethodsA total of 235 patients were enrolled in this study. Univariate and multivariate analyses were performed to screen for independent risk factors and construct a nomogram to predict the risk of cervical LN metastasis. The nomogram performance was assessed by discrimination, calibration, and clinical use.ResultsTotally, four independent predictors, including the maximum diameter of tumor, paraesophageal lymph node status, recurrent laryngeal nerve lymph node status, and the CT-reported cervical LN status, were enrolled in the nomogram. The AUC of the nomogram model in the training and validation dataset were 0.833 (95% CI 0.762–0.905), 0.808 (95% CI 0.696–0.920), respectively. The calibration curve demonstrated a strong consistency between nomogram and clinical findings in predicting cervical LN metastasis. Decision curve analysis demonstrated that the nomogram was clinically useful.ConclusionWe developed a nomogram that could be conveniently used to predict the individualized risk of cervical LN metastasis in patients with middle and lower thoracic ESCC.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis.

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure. The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups. A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups. Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

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.

Application of intraoperative nerve monitoring for recurrent laryngeal nerves in minimally invasive McKeown esophagectomy.

BackgroundMediastinal lymphadenectomy is of great importance during esophagectomy for esophageal squamous cell carcinoma. However, recurrent laryngeal nerve (RLN) injury is a severe complication caused by lymphadenectomy along the RLN. Intraoperative nerve monitoring (IONM) can effectively identify the RLN and reduce the incidence of postoperative vocal cord paralysis (VCP). Here, we describe the feasibility and effectiveness of IONM in minimally invasive McKeown esophagectomy.MethodsA total of 150 patients who underwent minimally invasive McKeown esophagectomy from 2016 to 2020 were enrolled in this study. We divided the patients into two groups: a neuromonitoring group (IONM, n = 70) and a control group (control, n = 80). Clinical data, surgical variables, and postoperative complications were retrospectively analyzed and compared.ResultsThere was no significant difference in baseline data between the two groups. Postoperative VCP occurred in six cases (8.6%) in the IONM group, which was lower than that in the control group (21.3%, P = 0.032). Postoperative pulmonary complications were found in five cases (7.1%) and 14 in the control group (18.8%, P = 0.037). The postoperative hospital stay in the IONM group was significantly shorter than that in the control group (8 vs. 12, median, P < 0.001). The number of RLN lymph nodes harvested in the IONM group was higher than that in the control group (13.74 ± 5.77 vs. 11.03 ± 5.78, P = 0.005). The sensitivity and specificity of IONM monitoring VCP were 83.8% and 100%, respectively. A total of 66.7% of patients with a reduction in signal showed transient VCP, whereas 100% with a loss of signal showed permanent VCP.ConclusionIONM is feasible in minimally invasive McKeown esophagectomy. It showed advantages for distinguishing RLN and achieving thorough mediastinal lymphadenectomy with less RLN injury. Abnormal IONM signals can provide an accurate prediction of postoperative VCP incidence.

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.

Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers

PurposeTo investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling.Materials and methodsPatients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed.ResultsEn bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment.ConclusionCertain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.

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.

A Novel Scoring System for Predicting the Metastases of Posterior Right Recurrent Laryngeal Nerve Lymph Node Involvement in Patients With Papillary Thyroid Carcinoma by Preoperative Ultrasound.

ObjectiveOur goal was to investigate the correlation between papillary thyroid carcinoma (PTC) characteristics on ultrasonography and metastases of lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN). There is still no good method for clinicians to judge whether a patient needs LN-prRLN resection before surgery, and we also wanted to establish a new scoring system to determine whether patients with papillary thyroid carcinoma require LN-prRLN resection before surgery.Patients and MethodsThere were 482 patients with right or bilateral PTC who underwent thyroid gland resection from December 2015 to December 2017 recruited as study subjects. The relationship between the PTC characteristics on ultrasonography and the metastases of LN-prRLN was analyzed by univariate and logistic regression analyses. Based on the risk factors identified in univariate and logistic regression analysis, a nomogram-based LN-prRLN prediction model was established.ResultLN-prRLN were removed from all patients, of which 79 had LN-prRLN metastasis, with a metastasis rate of 16.39%. Multivariate logistic regression analysis revealed that LN-prRLN metastasis was closely related to sex, age, blood supply, larger tumors (> 1 cm) and capsular invasion. A risk prediction model has been established and fully verified. The calibration curve used to evaluate the nomogram shows that the consistency index was 0.75 ± 0.065.ConclusionPreoperative clinical data, such as sex, age, abundant blood supply, larger tumor (> 1 cm) and capsular invasion, are positively correlated with LN-prRLN metastasis. Our scoring system can help surgeons non-invasively determine which patients should undergo LN-prRLN resection before surgery. We recommend that LN-prRLN resection should be performed when the score is above 103.1.

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.

Prone position thoracoscopic esophagectomy:preliminary experiences of thirty cases in Shanghai Chest Hospital

Objective: To examine the safety and short-term outcomes of prone position thoracoscopic esophagectomy. Methods: Clinical data of consecutive thirty patients who accepted prone position thoracoscopic esophagectomy at Department of Thoracic Surgery, Shanghai Chest Hospital between July and December 2020 was analyzed retrospectively. There were 25 males and 5 females, aging 65.5(29.0) years (M(QR))(range: 48 to 82 years). Patients with cT3-4a accounted for 73.3%(22/30) and cN(+) accounted for 43.4%(18/30). All the patients in this study had no serious comorbidity, accepted prone position thoracoscopic esophagectomy. Results: No conversion to thoracotomy occurred. The overall time of operation was 210 (105) minutes (range: 130 to 268 minutes), the time of thoracic procedures was 92 (46) minutes (range: 72 to 136 minutes), the time of abdominal procedures was 32 (14) minutes (range: 20 to 48 minutes), respectively. R0 resection accounted for 93.3%(28/30), the negative ratio of circumferential margin was 96.7%(29/30). The number of lymph nodes dissection was 21.5(7.2) (range: 16.0 to 28.0) in total, 12.0(6.5) (range: 9.0 to 18.0) in thoracic lymph nodes, 2.0(1.5) (range: 1.0 to 5.0) in left recurrent laryngeal nerve lymph nodes, and 1.0(1.0) (range: 1.0 to 3.0) in right recurrent laryngeal nerve lymph nodes, respectively. There was no perioperative death, and the overall postoperative complication rate was 43.3%(13/30). The incidence of anastomotic leakage was 10.0%(3/30), recurrent laryngeal nerve paralysis was 26.7%(8/30), and respiratory complication was 6.7%(2/30). The postoperative hospital stay was 10 (9) days (range: 5 to 42 days). Conclusion: Prone position thoracoscopic esophagectomy is safe and feasible, and the short-term outcomes is satisfactory.

Improving Outcome of Superior Mediastinal Lymph Node Dissection During Esophagectomy: A Novel Approach Combining Continuous and Intermittent Recurrent Laryngeal Nerve Monitoring.

This study aimed at demonstrating the effects and learning curve of utilizing combined intermittent and continuous recurrent laryngeal nerve (RLN) monitoring for lymphadenectomy during esophagectomy. RLN lymphadenectomy is oncologically important but is technically demanding. Vocal cord (VC) palsy as a result from RLN injury, carries significant morbidities. This is a retrospective study of consecutive esophageal squamous cell carcinoma (ESCC) patients who underwent transthoracic esophagectomy from 2010 to 2020. Combined nerve monitoring (CNM) included: CNM which involved a periodic stimulating left vagal electrode and intermittent nerve monitoring which utilized a stimulating probe to identify the RLNs. The integrity of the RLNs was assessed both intermittently and continuously. This technique was introduced in 2014. Patients were divided into "before CNM" and "CNM" groups. The primary outcome was the difference in number of RLN lymph nodes harvested and VC palsy rate. Learning curves were demonstrated by cumulative sum (CUSUM) analysis. Two hundred and fifty-five patients were included with 157 patients in "CNM" group. The mean number of RLN lymph nodes harvested was significantly higher (4.31 vs 0.45, P < 0.0001) for the "CNM" group. VC palsy rates were significantly lower (17.8% vs 32.7%, P = 0.007). There was an initial increase in VC palsy rate, peaked at around 46 cases. The increase in lymph nodes harvested above the mean plateaued at around 96 cases. CNM helped improve bilateral RLN lymphadenectomy. Lymph node harvesting was increased with reduction of VC palsy after a learning curve.