Recurrent Nerve Palsy Research Articles

A Case of Unilateral Recurrent Nerve Palsy Improved by Chemotherapy for Esophageal Cancer

A Case of Unilateral Recurrent Nerve Palsy Improved by Chemotherapy for Esophageal Cancer

Anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord via one vertebra with two bony channels for adjacent two-segment cervical spondylotic myelopathy: a technical note

BackgroundThe current treatments for adjacent two-segment cervical spondylotic myelopathy (CSM) include two-segment anterior cervical discectomy and fusion (ACDF) and single-segment anterior cervical corpectomy and fusion (ACCF). Long-term follow-up has demonstrated that both procedures have complications such as reduced cervical mobility, accelerated degeneration of adjacent segments and loosening of internal fixation screws. The purpose of this study is to demonstrate the feasibility, safety, and efficacy of anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord (APFETDSC) via one vertebra with two bony channels for the treatment of adjacent two-segment CSM and to present our surgical experience.MethodsAnterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord (APFETDSC) via one vertebra with two bony channels was performed for 12 patients with adjacent two-segment CSM with follow-up care for at least 12 months. The Visual analog scale (VAS) and the Japanese Orthopedic Association Score (JOA) were recorded, and modified Macnab criteria were used to evaluate the treatment excellence rate. Radiological examinations, including X-ray, computed tomography (CT) and magnetic resonance imaging (MRI), were used to evaluate spinal cord decompression, intervertebral stability and healing of the bony channel.ResultsAll 12 patients completed the operation successfully. No postoperative complications, such as dysphagia, Horner’s syndrome, or laryngeal recurrent nerve palsy, were found. The postoperative VAS and JOA scores were significantly improved compared with those before surgery(P < 0.001). According to the modified Macnab criteria, the clinical outcome was excellent in 8 cases, good in 3 cases and fine in 1 case at the final follow-up and the excellent and good rate was 91.7%. Postoperative and follow-up imaging showed significant spinal cord decompression, well-healed bony channels and no cervical instability.ConclusionsThis study is the first report of anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord via one vertebra with two bony channels. This procedure has the advantages of less trauma, faster recovery, fewer complications and no need to implant internal fixators. This is a minimally invasive, feasible and safe surgical procedure for patients with adjacent two-segment CSM.

372. INVESTIGATION OF RISK FACTORS OF POSTOPERATIVE PNEUMONIA IN MEDIASTINOSCOPIC ESOPHAGECTOMY

Abstract Background Pneumonia is a usual complication in esophagectomy. Although frequency of pneumonia in mediastinoscopic esophagectomy is low, risk factors for pneumonia are unclear. The risk factors are investigated. Methods Two hundred and forty-four patients with mediastinoscopic esphagectomy and gastric tube reconstruction for esophageal cancer from 2016 to 2021 in our hospital were retrospectively considered in the present study. Postoperative pneumonia was diagnosed as Clavien-Dindo grade 2 or higher. Patients were divided into two groups with (n = 21) and without (n = 223) pneumonia, and background, surgical factors, or histopathological factors were investigated. Results Post-operative pneumonia was observed in 21 patients (8.6%), and pre-operative albumin, PNI (&amp;lt; 45), PLR (&amp;gt; 122), and operative bleeding (&amp;gt;134) were significantly related with post-operative pneumonia in the univariate analysis (p &amp;lt; 0.05). Age and previous respiratory disease were also tended to be related with post-operative pneumonia, but not significant. Low PNI was an independent risk factor of post-operative pneumonia in the multivariate analysis (p = 0.047, OR = 2.74). Post-operative pneumonia was not related to the complications, such as anastomosis leakage or recurrent nerve paralysis. No correlation with postoperative pneumonia was observed even in patients with preoperative respiratory dysfunction. Discussion PNI has been reported to be useful as a predictor of postoperative complications. In the present study, it was also a predictor factor of postoperative pneumonia. Early nutritional intervention for undernourished esophageal cancer patients may prevent postoperative pneumonia. Conclusion Low PNI can be a predictive factor of postoperative pneumonia in the mediastinoscopic esophagectomy.

169. PROPENSITY SCORE MATCHING ANALYSIS OF THE EFFECT ON PROGNOSIS OF PROPHYLACTIC NECK DISSECTION FOR ESOPHAGEAL CANCER

Abstract Background There is still no definite evidence regarding the prognostic effect of #104 prophylactic dissection. Materials and Methods: We conducted a retrospective study of patients who underwent esophagectomy regarding the prognostic effect of #104 prophylactic dissection by propensity score matching analysis. Between 2012/1 and 2020/12, 302 patients with esophageal malignant tumors underwent radical subtotal esophagectomy via the right thoracic approach at our hospital. The histological types were limited to squamous cell carcinoma, adenocarcinoma, and basal cell carcinoma, and clinical (c)T4b (TNM 7th edition), cM1, cervical esophageal cancer, salvage surgery cases, R1/2 cases, and cases with synchronous advanced multiple cancers were excluded. This resulted in the analysis of the 220 cases comparing between the 3-filed and 2-filed dissection groups. R version 4.1.2 was used for statistical analysis. The predicted probability of #104 dissection was calculated by logistic regression model. Propensity score matching was performed to match patients between 2 groups according to age, tumor location, preoperative treatment, postoperative pneumonia, pathological (p)T factor, and pN factor by nearest neighbor method within caliper. P &amp;lt; 0.05 was considered statistically significant. Results Both DSS and DFS were significantly better in the 2-filed dissection group. Baseline characteristics showed that the 3-filed dissection group had significantly more patients of tumor location Mt and Ut, more squamous cell carcinoma as the histologic type, and more cases with preoperative treatment. In the 3-field dissection group, operative time was significantly longer and the postoperative complications was increased such as recurrent nerve palsy and cervical lymphatic leakage. Pathologic results showed higher grades of pT and pN. Four patients in the 3-field dissection group had p104 metastasis, and only 1 of these survived without recurrence. On the other hand, 5 patients of the 2-field dissection group had #104 as the first recurrence site, and 3 of these had simultaneous distant metastasis. There was no significant difference in DSS and DFS between groups after propensity score matching (DSS p = 0.852, DFS p = 0.768). Conclusions This retrospective study did not confirm a prognostic benefit of prophylactic dissection of the #104 region. This will be elucidated by results of the ongoing RCT, JCOG2013 trial.

278. MEDIASTINOSCOPIC ESOPHAGECTOMY WITH INTRAOPERATIVE NERVE MONITORING FOR ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA; A SINGLE-CENTER INITIAL EXPERIENCE

Abstract Background In recent years, adenocarcinoma of esophagogastric junction (EGJ) has been on the increase in Japan. Although laparoscopic resection by the transhiatal approach is commonly used, patients often have difficulty with mediastinal lymph node dissection and reconstruction after resection. Since 2020, we have been performing mediastinoscopic esophagectomy for EGJ adenocarcinoma patients with esophageal invasion exceeding 3 cm in length or with a large tumor diameter. We report on the short-term results of the surgery performed. Methods Of 15 patients with adenocarcinoma of the esophagogastric junction who underwent radical esophagectomy at our hospital during a 36-month period from January 2020 to December 2022, 5 patients underwent mediastinoscopic esophagectomy without thoracic incisions. Surgery consisted of mediastinoscopic and laparoscopic subtotal esophagectomy, mediastinal lymph node dissection, and posterior mediastinal gastric tube reconstruction with cervical anastomosis. In all cases, continuous left recurrent nerve monitoring was performed intraoperatively. Short-term surgical outcomes were evaluated in terms of age, gender, TNM classification, stage, preoperative complications, operation time, blood loss, tumor diameter, length of esophageal invasion, postoperative complications, and postoperative hospital stay. Results All five patients were male, with a mean age of 67.8 years. 4 of the 5 patients had preoperative complications. Tumor localization was Siewert classification type I in 4 patients and type II in 1. The average tumor length and esophageal invasion length was 44 ± 26 mm and 38 ± 11 mm respectively. The average operation time was 395 ± 29 minutes and blood loss was 38 ± 39 mL. Lymph node metastases was revealed in three patients. No postoperative anastomotic leakage or recurrent nerve palsy was observed. One patient developed postoperative aspiration pneumonia but was cured without reintubation. Conclusion Mediastinoscopic esophagectomy for EGJ adenocarcinoma was performed safely. RCTs conducted in Western countries reported that esophagectomy with cervical anastmosis is associated with higher rates of recurrent nerve palsy than esophagectomy by the transhiatal approach. The use of a mediastinoscope to visualize the recurrent nerve and the use of intraoperative nerve monitoring devices might reduce the frequency of recurrent nerve palsy.

405. SHORT-TERM OUTCOMES OF ROBOT-ASSISTED ESOPHAGECTOMY

Abstract Background Robot-assisted minimally invasive esophagectomy (RAMIE) has become widely performed in Japan, and the technique and short-term results have been accumulated. In our institute, we started with daVinci S in 2013, switched to Xi in 2018, and have experienced 110 cases so far. Method; Technique and Devices: Semi-prone position with the left upper extremity placed under the body, 4 ports +1 assist port (Air Seal), double bipolar system—is the basic approach. The right upper extremity is placed so that it is attached to the head to provide axillary working space, and orthoglass to avoid direct compression of the right upper arm and robotic 4th arm. The range of motion of the 4th arm in the lower mediastinum is limited by the patient’s physique, so assistant forceps are used to assist as needed. Be willing to invert the camera to view the back of the operative field. Intraoperative recurrent nerve monitoring (NIM) was used in all cases. Results Five surgeons have performed RAMIE procedures. There have been no cases of conversion to thoracoscopic or open thoracotomy. The thoracic procedure time was significantly longer in RAMIE (299 min:274 min) than in thoracoscopic MIE. Blood loss tended to be less (17.1 mL: 44.0 mL). The incidence of recurrent nerve palsy (CD grade I or higher) was 44%:37%, that of pneumonia (CD grade II or higher) was 19%:18% and perioperative complications were similar between the two groups. Comparing the first half of the period when RAMIE was initiated with the second half, there was a significant decrease in the amount of bleeding, surgery time, and incidence of pneumonia, indicating an improvement in technique due to the number of experienced cases. Conclusion RAMIE can be performed safely, although no clear advantages can be demonstrated compared to thoracoscopic MIE at this time. RAMIE has clear advantages in terms of visual magnification of the dissected layer and stability of the surgical field, therefore, it is expected to reduce complications due to improved technique.

Challenging routine: technical difficulties and solutions of endoscopic thyroidectomy via a combined transoral and breast approach - a case-series and learning curve.

Conventional cervical lymph node dissection often leaves large surgical scars, which seriously compromises the postoperative aesthetic effect and can affect the quality of life of patients. In this study, the safety and feasibility of robotic-assisted endoscopic thyroidectomy with central neck dissection (CND) and lateral neck dissection (LND) via a combined transoral and breast approach are discussed in detail. A retrospective analysis was made of the data of 26 patients with stage cN1b papillary thyroid carcinoma who were admitted to the Thyroid Surgery Department of the Hunan Cancer Hospital from March 2021 to September 2022 and who underwent robotic-assisted endoscopic thyroidectomy with LND via a combined transoral and breast approach. The demographic data, surgical indicators, postoperative data, and the postoperative complication rate of the patients were analyzed, and the learning curve was analyzed by cumulative summation. All the patients underwent endoscopic surgery without any conversion to open surgery. The mean operation time was 313.7±50.3min and the mean number of total positive/retrieved lymph nodes was 11.2±8.1/36.8±13.7. Two patients developed temporary laryngeal recurrent nerve palsy and three patients developed temporary hypoparathyroidism, all of whom recovered within 3 months postoperatively. No tumor recurrence occurred during follow-ups that ranged from 6 to 24 months. The mean postoperative quality of life (QOL) score was 189.1±118.2, test results ranging from 0 to 1300 with a lower score indicating a higher QOL, and the aesthetic satisfaction score was 4.2±0.7, test scores ranging from 0 to 5 with higher scores indicate higher satisfaction. The turning point of the learning curve was in the 11th case. The robotic-assisted endoscopic thyroidectomy with CND and LND via a combined transoral and breast approach is safe and feasible, and the improved cosmetic effect is remarkable, which is conducive to improving the postoperative QOL of patients. It provides a new surgical option for patients.

Intraoperative Nerve Monitoring during Minimally Invasive Esophagectomy and 3-Field Lymphadenectomy: Safety, Efficacy, and Feasibility.

The objective of this study was to demonstrate the safety, efficacy, and feasibility of intraoperative monitoring of the recurrent laryngeal nerves during thoracoscopic and robotic 3-field esophagectomy. This retrospective analysis details our initial experience using intraoperative nerve monitoring (IONM) during minimally invasive 3-field esophagectomy. Data were obtained from a prospectively maintained database and electronic medical records. The study included all patients who underwent minimally invasive (video-assisted thoracic surgery/robotic) transthoracic esophagectomy with neck anastomosis. The patients were divided into those who underwent IONM during the study period and a historical cohort who underwent 3-field esophagectomy without IONM at the same institution. Appropriate statistical tests were used to compare the 2 groups. Twenty-four patients underwent nerve monitoring during minimally invasive 3-field esophagectomy. Of these, 15 patients underwent thoraco-laparoscopic operation, while 9 received a robot-assisted procedure. In the immediate postoperative period, 8 of 24 patients (33.3%) experienced vocal cord paralysis. Relative to a historical cohort from the same institution, who were treated with surgery without nerve monitoring in the preceding 5 years, a 26% reduction was observed in the nerve paralysis rate (p=0.08). On follow-up, 6 of the 8 patients with vocal cord paralysis reported a return to normal vocal function. Additionally, patients who underwent IONM exhibited a higher nodal yield and a decreased frequency of tracheostomy and bronchoscopy. The use of IONM during minimally invasive 3-field esophagectomy is safe and feasible. This technique has the potential to decrease the incidence of recurrent nerve palsy and increase nodal yield.

Left recurrent nerve lymph node dissection in robotic esophagectomy for esophageal cancer without esophageal traction

BackgroundBecause the robotic arm is located on the dorsal side of the patient, when the esophagus is pulled dorsally for the left recurrent nerve lymph node (LRLN) dissection, the robotic arm interferes with the surgical field. This made it difficult to prepare for the left recurrent lymph node dissection. We developed LRLN dissection in robotic surgery with natural space creation by physiological organ movement and evaluated the short-term results.MethodsIn this retrospective study, we analyzed 102 cases of robot-assisted thoracoscopic subtotal esophagectomy (RATE) among radical subtotal esophagectomies performed between December 2018 and December 2022 using medical records. LRLN dissection is preceded by a dissection of the esophagus from the trachea. Leaving the esophagus on the vertebral side and away from the trachea resulted in a physiological elevation of the esophagus, providing space between the trachea and esophagus.ResultsThe thoracic surgery time in RATE was 181 (115–394) min. The number of LRLNs dissected was 4 (1–14). Six patients (6%) had a postoperative recurrence in the mediastinal lymph nodes. Seven patients (7%) had grade ≥ 1 left recurrent nerve palsy.ConclusionsLRLN dissection with RATE using natural space creation was performed safely with a sufficient number of dissected lymph nodes and little left recurrent nerve palsy.

Comparison of the Efficiency of Radiofrequency and Microwave Ablation Methods in the Treatment of Benign Thyroid Nodules

To compare the efficacy of two thermal ablation techniques (radiofrequency vs microwave ablation) in the treatment of benign thyroid nodules. A total of 80 patients with 80 nodules underwent thermal ablation of thyroid nodules with either radiofrequency ablation (RFA) (23 females and14 males; mean age 41±9years) or microwave ablation (MWA) (28 females and 15 males; mean age 45±11years). Ultrasound assessments were made at the 1st, 3rd, 6th, and 12th months after the ablation procedure. The mean initial volume of the nodules (RFA: 15.6mL [min 2.5-max 74]; MWA: 40mL [min 2-max 205]) was statistically significantly different (P<.001). The following were the volume reduction rates of nodules at 1, 3, 6, and 12months, respectively: after RFA: 46.8±13.5%, 62.9±13.6%, 71.6±11.9%, and 77.9±10.3%. After MWA: 38.7±12.5%, 54±15.3%, 59.6±12.5%, and 65±11.3%. For all months, volume reduction rates in the RFA group were significantly higher than those in the MWA group (P<.05). One patient treated by RFA reported an abscess formationand another patient treated by RFA had a self-limiting hematoma, whorecovered without any further treatment. Also, in the MWA group, one patient had abscess formation and another patient had transient recurrent nerve paralysis, who recovered with appropriate treatment. Both methods are effective in treating benign thyroid nodules;however, RFA provides a better volume reduction.

Left parathyroid carcinoma with secondary hyperparathyroidism: a case report

BackgroundParathyroid carcinoma is a rare disease with a frequency of 0.005% of all malignancies [1, 2]. Various aspects of its pathogenesis, diagnosis, and treatment remain poorly understood. Furthermore, cases with secondary hyperparathyroidism are fewer. In this case report, we describe a case of left parathyroid carcinoma with secondary hyperparathyroidism.Case presentationThe patient was a 54-year-old woman who had been on hemodialysis since the age of 40 years. At 53 years of age, her calcium levels were high, and she was diagnosed with drug-resistant secondary hyperparathyroidism and was referred to our hospital for surgical treatment. Blood tests revealed calcium levels of 11.4 mg/dL and intact parathyroid hormone (PTH) levels of 1007 pg/mL. Neck ultrasonography revealed a 22-mm large round hypoechoic mass, partially indistinct margins, and D/W ratio > 1 at the left thyroid lobe. Computed tomography scans revealed a 20-mm nodule at the left thyroid lobe. No enlarged lymph nodes or distant metastases were noted. 99mTc-hexakis-2-methoxyisobutylisonitrile scintigraphy revealed an accumulation at the superior pole of the left thyroid lobe. Laryngeal endoscopy revealed paralysis of the left vocal cord, signifying recurrent nerve palsy due to parathyroid carcinoma. Based on these results, a diagnosis of secondary hyperparathyroidism and suspected left parathyroid carcinoma was made, and the patient underwent surgery. Pathology results revealed hyperplasia in the right upper and lower parathyroid glands. The left upper parathyroid gland showed capsular and venous invasion, and the diagnosis was left parathyroid carcinoma. At 4 months post-surgery, calcium levels improved to 8.7 mg/dL and intact PTH levels to 20 pg/mL, with no signs of recurrence.ConclusionsWe report a case of left parathyroid carcinoma associated with secondary hyperparathyroidism. Concomitant secondary hyperparathyroidism may cause mild hypercalcemia compared to parathyroid carcinoma alone due to the added modification of dialysis. Although our patient also presented with mild hypercalcemia, a D/W ratio > 1 on preoperative echocardiography and presence of recurrent nerve palsy on laryngoscopy led to the suspicion and treatment of parathyroid carcinoma preoperatively.

Transient Facial Nerve Palsy in Aviation.

INTRODUCTION: Facial nerve palsy has been observed sporadically by aviation medicine doctors in recent years. We present two case reports of patients with the rare condition of facial nerve palsy occurring during aviation, along with a review of the literature, an overview of the phenomenon and the described symptoms of the cases. PubMed® including Medline® was searched using the terms nerve palsy and aviation with no restriction. In addition, two new cases of recurrent nerve palsy are described.CASE REPORTS: We describe two case reports: A 20-yr-old woman reported recurrent transient left-sided facial nerve palsy with increased duration and intensity on four subsequent flights, and a 35-yr-old woman who reported a left-sided transient facial nerve palsy 20 min after ascent.DISCUSSION: Included in the systematic review were 17 studies. Only case report studies were found. Including the two cases of facial nerve palsy described in this article, the reviewed studies represent 23 cases of peer-reviewed facial baro-palsy in aviation (ages 10 to 62 yr old). Having baro-palsy symptoms during flight is a rare condition, and the mechanism is not well understood. Some typical characteristics and possible mechanisms are discussed. PE tube insertion of the tympanic membrane has been found to be an effective treatment; however, further studies are needed.Bloch SL, Hertz J, Klokker M. Transient facial nerve palsy in aviation. Aerosp Med Hum Perform. 2023; 94(5):404-408.

Abstract #1402477: Sixth-Nerve Palsy in Uncontrolled Type 1 Diabetes with Insulin Dependence

Diabetic retinopathy is the most common and well-known ophthalmologic complications in diabetic patients. However, oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. Specifically, sixth nerve palsy is the most common, however infrequently studied. Our patient is a 51-year-old female with a past medical history of insulin-dependent diabetes mellitus, hypertension, chronic sinusitis, and chronic pain syndrome that presented with complaints of worsening headache and diplopia. Patient was hemodynamically stable on admission. Upon examination of the eye, the patient's right eye did not cross the midline in lateral gaze and was found to have diplopia in primary and lateral gaze of left eye. She was found to have recurrent sixth nerve palsy upon further evaluation of her visual deficit. Labs showed creatinine of 0.61 mg/dl (0.66-1.25 mg/dL), sodium of 129 mmol/L (135-145 mmol/L), potassium of 4.4 mmol/L (3.5-5.1 mmol/L), an anion gap of 2 mmol/L (3-13 mmol/L), blood glucose in the 300-400 mg/dL range (70-100 mg/dL) with most recent blood glucose of 168 mg/dL. Her hemoglobin A1C is 13.0 (< 6%). Her complete blood count shows a white blood cell count of 6,000/uL (3,600-10,700/uL) and a hemoglobin of 14 g/dL (13.0-18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. She was treated with basal insulin of 30 units nightly and bolus insulin of 3 units three times a day before meals for type 1 diabetes with hyperglycemia with long-term insulin use. Visual deficit was treated by observation by ophthalmology with symptomatic help through eyeglass prisms. She was discharged after one night of hospital stay with recommendations to control her home basal insulin with a carbohydrate-controlled bolus dose during meals. She was recommended to follow-up with endocrinology outpatient to discuss use of insulin pump to better control her diabetes. Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.

Abstract #1412731: Sixth-Nerve Palsy in a Patient with Type 1 Diabetes

Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications in patients with diabetes. Specifically, sixth nerve palsy is the most common. A 51-year-old female with a past medical history of type 1 diabetes on insulin and hypertension presented with complaints of worsening headache and diplopia. Physical exam was remarkable for recurrent sixth nerve palsy. Patient was hemodynamically stable. Labs showed blood glucose of 367 mg/dL (70-100 mg/dL), an anion gap of 2 mmol/L (3-13 mmol/L), creatinine of 0.61 mg/dl (0.66-1.25 mg/dL), sodium of 129 mmol/L (135-145 mmol/L), and potassium of 4.4 mmol/L (3.5-5.1 mmol/L). Her hemoglobin A1C was 13.0% Her complete blood count shows a white blood cell count of 6,000/uL (3,600-10,700/uL) and a hemoglobin of 14 g/dL (13.0-18.0 g/dL). Magnetic resonance venography of the head was negative for cerebral venous sinus thrombosis and magnetic resonance imaging of the brain was negative for acute abnormalities. Blood glucose readings improved during hospitalization after optimizing her insulin regimen. She was recommended to follow-up with outpatient endocrinology to discuss use of insulin pump to better control her diabetes. Sixth-nerve palsy is a frequent but lesser-known neuro-ophthalmologic complication of poorly controlled diabetic patients. Studies have shown a higher incidence of diabetes in patients with sixth-nerve palsy, warranting a more focused medical evaluation along with close observation and tighter control of blood glucose levels and hemoglobin A1C.

Subtotal Thyroidectomy Postoperative Complications with Unplanned Thyroid Surgery

Background: The surgical treatment for bilateral multinodular nontoxic goiter (BMNG) is still debatable. Avoiding RLN harm during thyroid surgery if the pathology is not identified. Reduce the incidence of hypoparathyroidism by reducing the rate of parathyroid gland damage during excision. Objective: To see the complications of subtotal thyroidectomy in random thyroid surgery. Materials and Methods: This was a prospective, observational study conducted in the Department of ENT &amp; Head- Neck surgery, Rangamati Medical College, Rangamati for a period of 2 years from January 2019 and December 2020. Total 100 patients were operated for benign and malignant thyroid disorders. This study was done to assess complications after various types of thyroid surgeries indicated for benign as well as malignant thyroid lesions. Results: Ten (10.0%) patients had transient hypocalcemia followed by 4(4.0%) had transient recurrent nerve palsy, 1(1.0%) had permanent hypocalcemia, 1(1.0%) had permanent recurrent nerve palsy and 1(1.0%) had neck hematoma. Mean weight of the resected thyroid was found 62.4±14.1 gram in euthyroidism group and 74.2±26.4 gram in hypothyroidism group. Mean proportion of weight of the thyroid remnant in total weight of the thyroid was found 5.1±2.2 percent in euthyroidism group and 3.9±2.1 percent in hypothyroidism group. Conclusion: Transient hypocalcemia, transient recurrent nerve palsy, chronic hypocalcemia, permanent recurrent nerve palsy, and neck hematoma were the most frequent postoperative complications.

Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review.

Since 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery. We conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported. Most studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure. There is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.

Patient with neck swelling.

An approximately 70-year-old female with a history of anaplastic thyroid cancer with metastasis to the lungs and cervical spine presented to the emergency department with a new fluctuant neck swelling of approximately 1 week's duration (Figure 1, Video 1). The mass was non-tender but oscillated paradoxically with respirations. The patient also noted a mildly hoarse voice. One month previously, she underwent total radical thyroidectomy with extensive soft tissue resection, including cricotracheal resection with primary re-anastomosis. The patient underwent computed tomography with contrast of the neck. (Figure 2). The computed tomography revealed a large, predominantly air-filled collection in the anterior neck measuring 7 × 6 × 6 cm and communicating with a contained tracheal perforation. The patient was taken to the operating room the following day, confirming breakdown of the cricotracheal repair. The patient underwent debridement and revision tracheostomy. Tracheal dehiscence is the complete disruption of the tracheal wall. This is in contrast to tracheal diverticulum, which represents an outpouching of the tracheal wall.1, 2 Anastomotic dehiscence occurs in 2.5%–11% of postoperative patients.3, 4 Known risk factors for dehiscence include diabetes and laryngotracheal resections, as well as long resections, pediatric age group, preoperative tracheostomy, and tension on the anastomosis. The current case is unusual in the timing of the diagnosis (1 month after surgery) and the large size of the perforation.5, 6 Surgical complications of tracheal repair may occur in up to 27% of patients. Bilateral recurrent nerve palsy is the most common complication. Other potential complications include anastomotic dehiscence, hypoparathyroidism, glottic edema, anastomotic stenosis, bleeding, respiratory insufficiency, and ventilator dependency.7, 8

The Significance of Increased Dose in the Outcome of Definitive Chemoradiotherapy at Doses above 60Gy for cT3-4 Cervical Esophageal Cancer: A Report of 83 Cases from a Single Institution

<h3>Purpose/Objective(s)</h3> We investigated whether increasing the RT dose from 60 Gy to 67-68 Gy, which is comparable to the dose for squamous cell carcinoma of the head and neck, would improve the treatment outcome in cT3-4NxM0 patients enrolled for definitive chemoradiotherapy (CRT) for locally advanced cervical esophageal cancer based on late adverse events and recurrence patterns. <h3>Materials/Methods</h3> From 2004 to 2020, 83 patients with cT3-4bNxM0 squamous cell carcinoma of the cervical esophagus (including 22 cases of Ce, 8 cases of CePh, and 53 cases of CeUt, but not UtCe) were enrolled in a radical CRT (1.8-2.1 Gy/F, total dose >60 Gy, and concurrent CDDP80mg/m²x1 and 5-fluorouracil 800 mg/m²x5, 2 courses) protocol at our institution. Pretreatment imaging, including MRI and ultrasound tracheal endoscopy, showed that 71% of 59 patients were cT4 (89% tracheal invasion) and the rest were cT3. cN1 or higher was found in 73 patients (88%) and cN0 in 10 patients (12%). Thirty-six patients were in the cohort group for VMAT of 67-68 Gy/33 F/7 wks with D50 indication for PTV, and the rest were in the non-cohort group. In the remaining 47 patients in the non-cohort (3DCRT) group, 30 patients were completed at 60 Gy (or less than 60 Gy for surgery), and only 14 patients underwent 3DCRT of 62 Gy or more, which was presumably added due to poor response. A total of four patients were judged to be candidates for salvage surgery at 50 Gy intermediate assessment: one in the cohort group and three in the non-cohort group. The median observation period for survivors was 87.4 months (95% CI: 65.0-109.7). <h3>Results</h3> OS was 30.3% (SE 5.4%) at 5 years in all cT3-4NxM083 patients. cT3/T4, cN0/N1, age, gender ratio, and tumor occupying subsite CePh/CeUt types in cohort vs. non-cohort were not significantly skewed. There was no significant difference in OS between the cohort group and the non-cohort group in the ITT comparison of all patients, including the 4 patients who were converted to surgery (Breslow, p=0.84). Multivariate analysis showed that the two factors significant for OS were cT3 vs. cT4 (p=0.035, HR=2.12) and tumor occupation site Ce/CePh vs. CeUt (p=0.047, HR=1.91). There was no significant difference in local recurrence and regional recurrence, 41.5% and 12.2% in the cohort group and 39.5% and 7.9% in the non-cohort group, respectively. The main late adverse events Grade 3 or higher were esophageal stenosis in 6 cases and bilateral recurrent nerve palsy in 1 case, but there was no significant difference between the cohort group (3 cases) and the non-cohort group (4 cases), and it could not be said to occur at doses higher than 60 Gy by dose. <h3>Conclusion</h3> It has long been pointed out that cervical esophageal cancer may require higher doses than thoracic esophageal cancer. However, in advanced cancers of cT3 or higher, treatment planning to obtain an appropriate dose distribution of 60 Gy or higher in VMAT did not directly lead to improved OS.

386. SURGICAL SHORT-OUTCOMES IN ELDERLY PATIENTS WITH ESOPHAGEAL CANCER IN OUR INSTITUTION

Abstract With aging, patients with esophageal cancer would have several comobidity and decline of physiological function. It is difficult to fit the standerd treatment to the elderly patients with esopageal camcer. We review the data of elderly patients who underwent operation for esopageal cancer in our institution to evaluate the safety of surgery in this partucular population. During January 2017 and December 2021, twenty three patients over 75-year-old underwent the operation with right thoracotomy, that is McKeown’s or Ivor-Lewis operation, for esophageal cancer or esophago-gastric junction cancer in our institution. We retrospectively analyzed their preoperative assessment, concurrent disorders, surgical techniques used, postoperative course, and complications. Average age of the patients was 79.5 years, and over 80 year-old patients were nine. Preoperative chemotherapy was done in 12 cases. Only 3 patients underwent esophagectomy with right thoracotomy and three-field lymph node dissection. Postoperative complications occurred in 17 patients (74%). Mortality was one cases, because of severe respiratory failure. Anastomotic leakage was observed in nine patients. As other complications over Grade II in Clavien-Dindo (CD) classification, anastomotic stricture was 4, pneumonia was 3 cases. Recurrent nerve paralysis was observed in 6 patients in Grade I in CD classification. It is difficult to decide treatment for esophageal cancer only at age. In elderly cases, it would require more ingenuity for anastomosis after esophagectomy.

407. A STUDY OF OUTCOMES OF ESOPHAGEAL CANCER SURGERY FOR ELDERLY PATIENTS OVER 80 YEARS OF AGE

Abstract According to the 2020 edition of the situation in Japan, the population aged 65 and over reached 35.89 million, accounting for 28.4% of the total population. Esophageal cancer is a common disease among the elderly, and it is expected that the number of encounters with elderly esophageal cancer patients will increase further in the future. We examined the outcomes of esophageal cancer surgery for elderly patients at our hospital. Of 769 thoracic esophageal cancer resections performed at our hospital from 2015–2019, 53 (6.8%) patients aged 80 years or older were included. The mean age was 82 (80–94) years, the male/female ratio was 45/8, tumor localization was Ut/Mt/Lt 5/23/25, and cStage (UICC 7th edition) was I/II/III/IV 12/8/30/3. The surgical technique was 1-stage resection/2-stage segmental resection/mediastinoscopy in 9/32/12 cases. Surgical complications were suture failure, recurrent nerve palsy, and pulmonary complications in 2/12/11 patients. The 3-year survival rate was 66.7%, and the 3-year recurrence-free survival rate was 62.1%. The 3-year survival rate was 66.7% and the 3-year recurrence-free survival rate was 62.1%. Esophageal cancer surgery may be a treatment option for elderly patients who are able to tolerate surgery, even if they are over 80 years of age. Our hospital provides a multidisciplinary team intervention for patients over 70 years of age 3–4 weeks prior to surgery, during the perioperative period, and after discharge, which may be useful in reducing postoperative complications.