Intraoperative ultrasonography for the identification of thoracic recurrent laryngeal nerve lymph nodes in patients with esophageal cancer

Abstract Description Background Lymphadenectomy along the left recurrent laryngeal nerve (RLN) in esophageal cancer is important for disease control but requires advanced dissection skills. Complete dissection of the lymph nodes along the left RLN in a safe manner is important. We demonstrate the reliable method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the prone position (TEP). Methods This procedure is performed for all of resectable thoracic esophageal cancers. The essence of this method is to recognize the lateral pedicle as a two-dimensional membrane that inclu replicatedes the left RLN, lymph nodes around the nerve, and primary esophageal arteries. By drawing the proximal portion of the divided esophagus and the lateral pedicle, identification and reliable cutting of the primary esophageal arteries and distinguishing the left RLN from the lymph nodes are simplified. Results We performed 46 TEPs for esophageal cancer using this method with no conversion to an open procedure in 2015 at Kobe University. No intraoperative morbidity related to the left RLN was observed. The mean number of harvested lymph nodes along the left RLN was 6.9 ± 4.2. Left RLN palsy greater than Clavien-Dindo classification grade II occurred in 4 patients (8%), all of them were reversible. The incidence of lymph node metastasis along the left RLN was 22%. Conclusion Our method for lymphadenectomy along the left RLN during TEP is safe and reliable. It has a low incidence of left RLN palsy and provides sufficient lymph node dissection along the left RLN. Disclosure All authors have declared no conflicts of interest.

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RA07.05: DIAGNOSTIC VALUE OF INTRAOPERATIVE ULTRASONOGRAPHY IN ASSESSING THORACIC RECURRENT LARYNGEAL NERVE LYMPH NODES IN PATIENTS WITH ESOPHAGEAL CANCER

Diseases of the Esophagus ◽

10.1093/dote/doy089.ra07.05 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 35-35

Author(s):

Hong Yang

Keyword(s):

Esophageal Cancer ◽

Recurrent Laryngeal Nerve ◽

Predictive Value ◽

Conflicts Of Interest ◽

Nodal Metastasis ◽

Laryngeal Nerve ◽

Intraoperative Ultrasonography ◽

Nodal Metastases ◽

Thoracic Esophageal Cancer ◽

Significant Difference

Abstract Background To evaluate the ability of intraoperative ultrasonography (IU) to detect recurrent laryngeal nerve (RLN) nodal metastases in esophageal cancer patients. Methods Sixty 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. Results The 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 (c2 = 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 (c2 = 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 (c2 = 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 (c2 = 10.819, P = .004). No significant differences were observed in PPV or NPV for these examinations when diagnosing left RLN nodal metastases. Conclusion Intraoperative ultrasonography showed superior sensitivity compared with preoperative CT or EUS in detecting RLN lymph node metastasis in patients with thoracic esophageal cancer. Disclosure All authors have declared no conflicts of interest.

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P152 CLINICAL PREDICTIVE MODEL OF LYMPH NODE METASTASIS AT RIGHT RECURRENT LARYNGEAL NERVE ZONE IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Diseases of the Esophagus ◽

10.1093/dote/doz092.152 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Li Zhigang ◽

Li Baiwei ◽

Li Bin ◽

Yang Yang

Keyword(s):

Squamous Cell Carcinoma ◽

Esophageal Cancer ◽

Lymph Node ◽

Lymph Node Metastasis ◽

Esophageal Squamous Cell Carcinoma ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Laryngeal Nerve ◽

Node Metastasis ◽

Short Diameter

Abstract Aim The aim of this study is to establish a clinical predictive standard for lymph node metastasis at this location by retrospectively comparing the traditional imaging findings of RRLN lymph nodes in esophageal squamous cell carcinoma with postoperative pathology. Background The right recurrent laryngeal nerve (RRLN) is the zone most prone to lymph node metastasis of esophageal squamous cell carcinoma. Although the survival benefit is large after surgical dissection, however, the postoperative mortality rate is significantly increased if the nerve is injured. How to selectively perform lymph node dissection at this location has always been a clinical problem that needs to be addressed. In the past, clinical evaluations mostly used lymph node short diameter ≥1cm as the diagnostic criteria for metastasis, which significantly underestimated the actual clinical situation. Methods 308 patients with thoracic esophageal squamous cell carcinoma who underwent surgical treatment in Shanghai Chest Hospital from Jan 2018 to Dec 2018 were retrospectively analyzed. According to imaging 1mm layer thickness enhanced CT as a tool, the RRLN lymph node short diameter (ctNd) size was measured. All patients were divided into four groups: (A) CT images without RRLN lymph node, (B) CT images with RRLN lymph node was 0<ctNd<5mm, (C) CT images with RRLN lymph node was 5mm≤ctNd<10mm, (D) CT images with RRLN lymph node was ctNd≥10mm. The RRLN lymph node metastasis of each group was analyzed, and the influencing factors were analyzed to establish a predictive model. Results Among all patients, 87.6% of the patients had lymph nodes detected in the RRLN surgical specimens. The sampling rate was 14.5% (121/832), the RRLN lymph node metastasis rate was 19.48%, and the total lymph node metastasis rate was 48.7%. RRLN lymph nodes (57.1%) (A-132, B-43, C-125, D-9) were seen in the preoperative CT scan of 176 patients. The postoperative pathological RRLN lymph node metastasis rate was 9.1%, 18.6%, 27.2% and 66.7%, respectively (P=0.01). Multivariate analysis showed that ctNd, tumor location and N stage were risk factors for RRLN lymph node metastasis (P<0.05). The risk of upper esophageal cancer metastasis was higher than middle segment esophageal cancer (28.2% vs 18.6%, P<0.05). The higher the risk of right laryngeal lymph node metastasis was detected in the later N stage (cN0-13.2%, cN1-21.5%, cN2-46.7%, P<0.05). The 6.5mm short diameter of RRLN lymph nodes on CT scan is the critical value of metastasis at this position (sensitivity 50%, specificity 83.5%), and the higher the risk of metastasis was seen in the larger the short diameter (P<0.05). Conclusion More than 6.5mm short diameter in the CT scan image should be the clinical predictor of lymph node metastasis of the right recurrent laryngeal nerve. The higher risk of metastasis was seen in the greater short diameter. Upper esophageal cancer and multiple lymph node metastasis increase the risk of RRLN lymph node metastasis. Key words esophageal cancer, lymph node metastasis, recurrent laryngeal nerve, computed tomography

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Outcomes of Esophageal Cancer after Esophagectomy in the Era of Early Injection Laryngoplasty

Diagnostics ◽

10.3390/diagnostics11050914 ◽

2021 ◽

Vol 11 (5) ◽

pp. 914

Author(s):

Tuan-Jen Fang ◽

Yu-Cheng Pei ◽

Yi-An Lu ◽

Hsiu-Feng Chung ◽

Hui-Chen Chiang ◽

...

Keyword(s):

Esophageal Cancer ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Laryngeal Nerve ◽

Resected Specimen ◽

Survival Outcomes ◽

Injection Laryngoplasty ◽

Radical Lymph Node Dissection ◽

Maximum Phonation Time ◽

Early Injection

(1) Background: severe weight loss was reported to be related to unilateral vocal fold paralysis (UVFP) after esophagectomy and could thus impair survival. Concomitant radical lymph node dissection along the recurrent laryngeal nerve during esophageal cancer surgery is controversial, as it might induce UVFP. Early intervention for esophagectomy-related UVFP by administering intracordal injections of temporal agents has recently become popular. This study investigated the survival outcomes of esophagectomy for esophageal squamous cell carcinoma (ESCC) after the introduction of early injection laryngoplasty (EIL). (2) Methods: a retrospective review of patients with ESCC after curative-intent esophagectomy was conducted in a tertiary referral medical center. The necessity of EIL with hyaluronic acid was comprehensively discussed for all symptomatic UVFP patients. The survival outcomes and related risk factors of ESCC were evaluated. (3) Results: among the cohort of 358 consecutive patients who underwent esophagectomy for ESCC, 42 (11.7%) showed postsurgical UVFP. Twenty-nine of them received office-based EIL. After EIL, the glottal gap area, maximum phonation time and voice outcome survey showed significant improvement at one, three and six months measurements. The number of lymph nodes in the resected specimen was higher in those with UVFP than in those without UVFP (30.1 ± 15.7 vs. 24.6 ± 12.7, p = 0.011). The Kaplan–Meier overall survival was significantly better in patients who had UVFP (p = 0.014), received neck anastomosis (p = 0.004), underwent endoscopic resection (p < 0.001) and had early-stage cancer (p < 0.001). Multivariate Cox logistic regression analysis showed two independent predictors of OS, showing that the primary stage and anastomosis type are the two independent predictors of OS. (4) Conclusion: EIL is effective in improving UVFP-related symptoms, thus providing compensatory and palliative measures to ensure the patient’s postsurgical quality of life. The emerging use of EIL might encourage cancer surgeons to radically dissect lymph nodes along the recurrent laryngeal nerve, thus changing the survival trend.

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P179 THORACOSCOPIC EXTENDED 2-FIELD LYMPH NODE DISSECTION FOR ESOPHAGEAL CANCER. IMPLEMENTATION AND SURGICAL TECHNIQUE

Diseases of the Esophagus ◽

10.1093/dote/doz092.179 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Eleandros Kyros ◽

Konstantinos Zografos ◽

Ilias Vagios ◽

Natasha Hasemaki ◽

Lysandros Karydakis ◽

...

Keyword(s):

Esophageal Cancer ◽

Lymph Node ◽

Surgical Technique ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Prone Position ◽

Lymph Node Dissection ◽

Laryngeal Nerve ◽

Node Dissection ◽

The Right

Abstract Aim Lymphadenectomy in minimally-invasive esophageal cancer surgery still remains challenging and standardization of surgical procedures is of extreme importance. The aim of this study is to present our safe and reproducible technique in thoracoscopic superior lymphadenectomy during esophagectomy for cancer. Background & Methods In esophageal cancer surgery, dissection of the superior mediastinal lymph-nodes is of high importance. For adequate mediastinal lymph-node dissection, an extensive operating field is required along with appropriate equipment and experience. Thoracoscopy in prone position provides excellent visualization of the operative field comparing to thoracotomic phase. A step-by-step explanation of our surgical technique during thoracoscopic superior lymphadenectomy is provided. Results All patients were placed in prone position. The entire posterior mediastinal pleura was incised; azygos arch was divided with clips, facilitating dissection of the left side of the posterior mediastinum. The descending thoracic aorta was freed anteriorly, separating the esophagus; the thoracic duct was dissected and divided with vascular clips. Esophageal hiatus was dissected circumferentially and the esophageal wall was freed from the pericardiumanteriorly. Subcarinal lymph-nodes were dissected en bloc. Upper thoracic esophagus was separated from the membranous part of the trachea. The right recurrent laryngeal nerve lymph nodes were dissected at the level of the right subclavian artery, with extreme caution to avoid nerveinjury. Left recurrent laryngeal nerve was identified by posterior traction of the esophagus using a full thickness transluminal suture;by pulling it through a separate skin incision, the relative lymph nodes were dissected. Conclusion It is interesting that, higher number of lymph-nodes are harvested with this procedure which may be the result of better visualization/access. Overall, our technique has been standardized, is safe and reproducible and could be adopted by specialized Upper GI Units.

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342 SURGICAL TREATMENT OF ESOPHAGEAL CANCER WITH VARIATIONS OF THE AORTIC ARCH AND ITS BRANCHES

Diseases of the Esophagus ◽

10.1093/dote/doab052.342 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Baiwei Li ◽

Liang Dai ◽

Haoyao Jiang ◽

Zhigang Li ◽

Keneng Chen

Keyword(s):

Esophageal Cancer ◽

Surgical Treatment ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Aortic Arch ◽

Subclavian Artery ◽

Laryngeal Nerve ◽

Aberrant Right Subclavian Artery ◽

Significant Group ◽

Term Survival

Abstract The variations of the aortic arch and its branches are rare. The surgical treatment of esophageal cancer would be challenged for combination with this anomaly. This study intends to review significant group cases to analyze the influence of this variation on esophagectomy. Methods From 2013 to 2019, 19 patients with aortic arch and brachiocephalic vessels variations underwent esophagectomy, accounting for 0.3% during the same period. The abnormalities were distributed as follows: left-sided aortic arch combined with aberrant right subclavian artery (LAA + ARSA) occurred 13 cases, right-sided aortic arch anomalies with mirror image arch branches (RAA + MIAB) in 1 case, and right-sided aortic arch combined with aberrant left subclavian artery (RAA + ALSA) in 5 case. Of the patients with LAA + ARSA, 11 patients underwent the McKeown esophagectomy, and 2 patients via transhiatal. All patients with RAA underwent left thoracotomy approach.Perioperative outcomes and long-term survival were analyzed. Results The tumors were mostly located in the upper and middle thorax (47.4% and 42.1%). The R0 resection rate was 89.5% (17/19). Recurrent laryngeal nerve injury occurred in 2 patients, anastomotic fistula in 1 patient. Two patients died within 30 days postoperatively. The yield of lymph nodes was 21.8 ± 9.4. The sampling rate of lymph nodes along the recurrent laryngeal nerve was 61.5% in LAA + ARSA group, while 16.7% in RAA group. Recurrence happened in 5 cases (29.4%), including 2 regional relapse. Four patients died after recurrence, with a median time to death of 20 months (range: 10–48 months). Conclusion For aortic arch and brachiocephalic artery variations in esophageal cancer, aberrant right subclavian artery and right-sided aortic arch are the most common types. The surgical strategy is closely related to the aortic arch position. Due to the combined variation of the recurrent laryngeal nerve, the upper mediastinal lymph nodes dissection would be conservative, but with acceptable oncologic results.

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PS01.221: IMPROVED TECHNIQUES AND TREATMENT OUTCOMES IN SINGLE-PORT MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.221 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 112-113

Author(s):

Hitoshi Fujiwara ◽

Atsushi Shiozaki ◽

Hirotaka Konishi ◽

Toshiyuki Kosuga ◽

Takeshi Kubota ◽

...

Keyword(s):

Overall Survival ◽

Esophageal Cancer ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Treatment Outcomes ◽

Single Port ◽

Laryngeal Nerve ◽

En Bloc ◽

Radical Esophagectomy ◽

Cervical Approach

Abstract Background We have improved the transcervical procedures for radical esophagectomy without thoracotomy for esophageal cancer since 2014, based on the excellent handling and visibility in the deep mediastinum provided by single-port mediastinoscopic technique. This study was to present our latest procedures of single-port mediastinoscopic radical esophagectomy and treatment outcomes for esophageal cancer. Methods (Surgical procedure) First, en bloc lymphadenectomy in the upper and middle mediastinum was performed including the lymph nodes along the left recurrent laryngeal nerve and tracheal bifurcation (subcarinal and bilateral main bronchial lymph nodes) by using a left cervical approach with a single-port mediastinoscopic technique, then, the lymph nodes along the right recurrent laryngeal nerve was done under direct vision by using a right cervical approach. Following the cervical procedures, the esophagus was completely mobilized with en bloc lymphadenectomy in the lower mediastinum by using a laparoscopic transhiatal approach. Finally, the cervical esophagus was transected, and the esophagus was resected through the abdominal incision. This operation was indicated not only for the patients with clinical T1–2 tumors, but also for those with clinical T3 tumors which showed a good response to preoperative chemotherapy. The perioperative outcomes of 111 patients who underwent this operation were reviewed. In addition, overall survival was analyzed and compared between transthoracic and transmediastinal esophagectomy groups (TTE, n = 177 vs. TME, n = 131). Results The background characteristics were as follows; squamous/adeno, 106/5; Ce/Ut/Mt/Lt/Ae, 2/20/58/26/5; cT1–2/T3, 51/60; cN0/N1–2, 53/58; cM0/M1lym, 104/7; cStage I-II/III-IV, 62/49 (TNM7th); preoperative chemotherapy (yes/no), 64/47. The operation time and blood loss were 370 min and 205 ml (median), respectively, and R0 resection rates were 97.3%. Postoperatively, pneumonia was observed in 8 patients (7.2%, C-D grade II or more), while vocal cord palsy was detected in 33 patients (29.7%, C-D grade I or more). Recent introduction of intraoperative nerve monitoring with NIM response 3.0 significantly reduced the palsy in laryngoscopic findings. Overall survival was not significantly different in each clinical stage between TTE and TME groups. Conclusion Single-port mediastinoscopic esophagectomy is feasible as a radical and minimally invasive option for esophageal cancer. Disclosure All authors have declared no conflicts of interest.

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P223 BILATERAL RECURRENT LARYNGEAL NERVE LYMPHADENECTOMY DURING THORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION

Diseases of the Esophagus ◽

10.1093/dote/doz092.223 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

R Jiménez-Rosellón ◽

F Mingol ◽

A Navío ◽

M Bruna ◽

E Álvarez ◽

...

Keyword(s):

Esophageal Cancer ◽

Lymph Node ◽

Minimally Invasive ◽

Lymph Nodes ◽

Recurrent Laryngeal Nerve ◽

Prone Position ◽

Lymph Node Dissection ◽

Mediastinal Lymph Node ◽

Laryngeal Nerve ◽

Node Dissection

Abstract Aim To present a video of a complete bilateral recurrent laryngeal nerve lymphadenectomy performed during minimally invasive esophagectomy using thoracoscopic video-assisted surgery in the prone position. Background and Methods Surgical treatment for esophageal cancer needs detailed lymphadenectomy. Indeed, the number of surgically dissected lymph nodes is important for staging accuracy and also determines patient’s prognosis, including those along the recurrent laryngeal nerve. However, recurrent laryngeal nerve dissection remains difficult and increases the appearance of postoperative complications. This is a video of a bilateral recurrent laryngeal nerve lymphadenectomy during thoracoscopic esophagectomy performed in the prone position in a female patient with esophageal cancer. Results A 75 year-old female was diagnosed with recurrent squamous cell middle third esophageal carcinoma. The patient had first been diagnosed eleven years ago, receiving chemoradiotherapy as a radical treatment. The patient achieved a complete response after treatment, which remained for eleven years. Eleven years later, during routine follow-up, tumor recurrence was identified in the middle third of the esophagus. After presentation in a Multidisciplinary Group the patient underwent minimally invasive McKeown esophagectomy. First, a video-assisted thoracoscopic surgery was performed in the prone position to mobilize the thoracic esophagus and complete a detailed mediastinal lymph node dissection, including infra-carinal lymph nodes, bilateral bronchial lymph nodes and also bilateral recurrent laryngeal nerve lymph nodes. Afterwards, the abdominal esophagus and lymph node dissection is performed using a laparoscopic approach, and also a left cervicotomy in the supine position. An assistance laparotomy was made to externalize the specimen and make the gastric conduit. A manual end-to end esophago-gastric anastomosis was executed and finally, a feeding jejunostomy tube was placed. The patient presented a benign postoperative course, introducing enteral nutrition and oral intake developing no complications, such as dysphonia, nor dysphagia and was discharged on the 8th postoperative day. The postoperative barium swallow radiography showed no leaks nor other complications and pathology report confirmed tumor free resection margins. Conclusion Detailed mediastinal lymph node dissection and exhaustive bilateral recurrent laryngeal nerve lymphadenectomy can be safely performed by minimally invasive surgery, as is shown in the video. The technique shown is feasible, achieves a complete lymph-node dissection and avoids postoperative complications such as dysphonia and recurrent laryngeal nerve palsy.

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