Hiroyuki Kobayashi, MD, PhD, Masato Kondo, MD, Motoko Mizumoto, MD, Ryosuke Kita, MD, Hideyuki Masui, MD, Shoichi Kitano, MD, Yukiko Kumata, MD, Takaaki Matsubara, MD, Keiichi Shiokawa, MD, Kenji Uryuhara, MD, PhD, Hiroki Hashida, MD, PhD, Koji Kitamura, MD, PhD, Ryo Hosotani, MD, PhD, Satoshi Kaihara, MD, PhD. Kobe City Medical Center General Hospital
Introduction: As the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (RLN), it is crucial to perform complete lymph node dissection along the RLN without complications. Although Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of IONM during esophageal surgery has not become common. Here, we describe our procedures focusing on a lymphadenectomy along the RLN utilizing the IONM.
Methods and Procedures: We first dissect ventral and dorsal side of the esophagus preserving the membranous structure (Meso-esophagus), which contains tracheoesophageal artery, RLN and lymph nodes. We next identify the location of the RLN which runs in the Meso-esophagus using IONM before visual contact. After that, we perform lymphadenectomy around the RLN preserving the nerve. This technique was evaluated in 30 consecutive cases (neural monitoring group; Nm) of esophagectomy in prone positioning, and compared with our historical 56 cases (conventional method group; Cm).
Results: In all 30 cases of Nm group, we could obtain the location information of the left RLN before the nerve comes in sight. Sensitivity and specificity of the IONM to detect the RLN paralysis was 92% and 80% each. The operation time of thoracic part was significantly longer in Nm group compared to Cm group (279 min vs. 254 min each, p=0.003). The number of resected lymph nodes were similar in each groups (Nm: 3.3±2.6 vs. Cm: 2.9±2.6, p=0.15). Grade 1 and more RLN paralysis according to the Clavien-Dindo classification were seen in 5 cases (16.7%) after surgical operation in Nm group, which was lower than that in the Cm group (18/56, 32.1%, p=0.12). Grade 2 and more RLN paralysis were also lower in Nm group than Cm group although not statistically significant (1/30, 3.3% vs. 6/56, 10.7%, p=0.20). As a result, median postoperative hospital stay was significantly shorter in Nm group than Cm group (22 days vs. 39 days each, p=0.0003).
Conclusions: Meso-esophagus oriented lymph nodes resection using IONM has substantial advantages to perform accurate and safe lymphadenectomy around the left RLN during prone esophagectomy. It could decrease the RLN paralysis and postoperative hospital stay after esophagectomy.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86446
Program Number: P433
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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