1
|
Komatsu S, Konishi T, Matsubara D, Soga K, Shimomura K, Ikeda J, Taniguchi F, Fujiwara H, Shioaki Y, Otsuji E. Continuous Recurrent Laryngeal Nerve Monitoring During Single-Port Mediastinoscopic Radical Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2022; 26:2444-2450. [PMID: 36221021 DOI: 10.1007/s11605-022-05472-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/03/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although single-port mediastinoscopic radical esophagectomy is ultimate minimally invasive surgery for esophageal cancer without thoracotomy or the thoracoscopic approach, the high incidence of recurrent laryngeal nerve (RLN) palsy remains a pivotal clinical issue. METHODS This study included 41 patients who underwent single-port mediastinoscopic radical esophagectomy with mediastinal lymphadenectomy between September 2014 and March 2022. Among these, continuous nerve monitoring (CNM) for RLN was done in 25 patients (CNM group), while the remaining 16 patients underwent without CNM (non-CNM group). Clinical benefits of CNM for RLN were evaluated. RESULTS The overall incidence of postoperative RLN palsy was 14.6% (6/41). The CNM group showed a significantly lower incidence of postoperative RLN palsy as compared to the non-CNM group (P = 0.026: CNM vs. non-CRNM: 4.0% (1/25) vs. 31.2% (5/16)). The CNM group had a lower incidence of postoperative pneumoniae (CNM vs. non-CNM: 4.0% (1/25) vs. 18.8% (3/16)) and shorter days of postoperative hospital stay (CNM vs. non-CNM: 13 days vs. 41 days). Multivariate analysis revealed that the CNM use (odds ratio 0.07; 95% CI 0.05-0.98) was an independent factor avoiding postoperative RLN palsy. CONCLUSION The CNM for RLN contributes to a remarkable reduction in the risk of postoperative RLN palsy and improvement in outcomes in single-port mediastinoscopic radical esophagectomy.
Collapse
Affiliation(s)
- Shuhei Komatsu
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan. .,Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | - Tomoki Konishi
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Daiki Matsubara
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Koji Soga
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Katsumi Shimomura
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Jun Ikeda
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Fumihiro Taniguchi
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Yasuhiro Shioaki
- Department of Digestive Surgery (Esophageal and Gastric Surgery Division), Kyoto First Red Cross Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery (Esophageal and Gastric Surgery Division), Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| |
Collapse
|
2
|
Yuda M, Nishikawa K, Ishikawa Y, Takahashi K, Kurogochi T, Tanaka Y, Matsumoto A, Tanishima Y, Mitsumori N, Ikegami T. Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy. Surg Endosc 2022; 36:3957-3964. [PMID: 34494155 DOI: 10.1007/s00464-021-08716-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Despite the risk of recurrent laryngeal nerve (RLN) palsy during esophagectomy, no established method of monitoring RLN injury is currently available. METHODS This study included 187 patients who underwent esophagectomy between 2011 and 2018. Among these, intraoperative nerve monitoring (IONM) was done in 142 patients (IONM group), while the remaining 45 patients underwent conventional surgery without IONM (control group). We investigated the incidence of postoperative complications with regard to the use of IONM. RESULTS The overall incidence of postoperative RLN palsy was 28% (52/187). The IONM group showed a significantly lower incidence of postoperative RLN palsy as compared to that in the control group (p = 0.004). The overall incidence of postoperative pneumonia was 22% (41/187) in those with Clavien-Dindo (CD) classification beyond grade 2. There were no significant differences between the incidence of any grade of postoperative pneumonia and the use of IONM (p = 0.195 and 0.333; CD > 2 and > 3, respectively). Multivariate analysis demonstrated that tumors in the upper third [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.04-9.29] and lack of IONM use (OR 2.51; 95% CI 1.17-5.38) were independent factors causing postoperative RLN palsy after esophagectomy. CONCLUSION IONM helps to reduce the risk of postoperative RLN palsy after esophageal cancer surgery.
Collapse
Affiliation(s)
- Masami Yuda
- Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa-shi, Chiba, 277-8567, Japan.
| | - Katsunori Nishikawa
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshitaka Ishikawa
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Kurogochi
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yujiro Tanaka
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Matsumoto
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichiro Tanishima
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Norio Mitsumori
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Gastroenterological Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
3
|
Takeda S, Iida M, Kanekiyo S, Nishiyama M, Tokumitsu Y, Shindo Y, Yoshida S, Suzuki N, Yoshino S, Nagano H. Efficacy of intraoperative recurrent laryngeal neuromonitoring during surgery for esophageal cancer. Ann Gastroenterol Surg 2021; 5:83-92. [PMID: 33532684 PMCID: PMC7832964 DOI: 10.1002/ags3.12394] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/19/2022] Open
Abstract
AIM To evaluate the efficacy of intraoperative neuromonitoring in identifying recurrent laryngeal nerves and decreasing the incidence of nerve injury in minimally invasive esophagectomies for esophageal cancers. METHODS A total of 167 minimally invasive esophagectomy patients were retrospectively reviewed. They were divided into intraoperative neuromonitoring (n = 84) and no intraoperative neuromonitoring (n = 83) groups, based on whether or not intraoperative neuromonitoring was used during surgery. We compared short-term surgical outcomes and incidence of recurrent laryngeal nerve palsy between the two groups before and after propensity score matching. The association between the loss of signal and recurrent laryngeal nerve palsy was also evaluated. RESULTS The incidence of recurrent laryngeal nerve palsy (grade 2 and higher) was lower in the intraoperative neuromonitoring group than in the no intraoperative neuromonitoring group (6.0% vs 21.2%, P = 0.02). The rate of recurrent laryngeal nerve palsy recovery within 6 months was also significantly higher in the intraoperative neuromonitoring group (87.5% vs 20.0%, P < 0.01). The positive and negative predictive values of intraoperative neuromonitoring for recurrent laryngeal nerve palsy were 60% (9/15) and 86.9% (60/69), respectively. The duration from paralysis to recovery was shorter in recurrent laryngeal nerve palsy cases with negative loss of signal results than in cases with positive loss of signal results (median: 43 days vs 95 days). CONCLUSION Intraoperative neuromonitoring is useful in identifying recurrent laryngeal nerves and may aid in reducing the incidence of recurrent laryngeal nerve injury during esophageal surgery.
Collapse
Affiliation(s)
- Shigeru Takeda
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Michihisa Iida
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Shinsuke Kanekiyo
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Mitsuo Nishiyama
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Yukio Tokumitsu
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Yoshitaro Shindo
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Shin Yoshida
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | - Nobuaki Suzuki
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| | | | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine SurgeryYamaguchi University Graduate School of MedicineYamaguchiJapan
| |
Collapse
|
4
|
Moritz A, Schmidt J, Schreiner W, Birkholz T, Sirbu H, Irouschek A. Combined recurrent laryngeal nerve monitoring and one-lung ventilation using the EZ-Blocker and an electromyographic endotracheal tube. J Cardiothorac Surg 2019; 14:111. [PMID: 31217035 PMCID: PMC6585134 DOI: 10.1186/s13019-019-0927-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/03/2019] [Indexed: 01/01/2023] Open
Abstract
Background Intraoperative neuromuscular monitoring (IONM) is a widespread procedure to identify and protect the recurrent laryngeal nerve (RLN) during thyroid surgery. However, for left thoracic surgery with high risk of RLN injury, both reliable recurrent laryngeal nerve monitoring and one-lung ventilation could interfere. Methods In this prospective study, a new method for IONM during one-lung ventilation combining RLN monitoring with an electromyographic (EMG) endotracheal tube (ETT) and lung separation using the EZ-Blocker (EZB) is described and its clinical feasibility and effectiveness were assessed. Results A total of 14 patients undergoing left upper lobe surgery and left upper mediastinal lymph node dissection were enrolled. The EZB was introduced and positioned without any problems and sufficient lung collapse was achieved in all patients. No tracheobronchial injuries or immediate complications occurred. A stable EMG signal was present in all patients and no RLN palsy and no negative side effects of the NIM EMG ETT or the EZB were observed postoperatively. Conclusions The described method is technically feasible, easy to apply and save. It provides both reliable IONM and independent lung separation for optimal surgical exposure. The combined use of the EZB and the NIM EMG ETT might reduce the risk for RLN palsy and impaired lung separation during left thoracic surgery with high risk for RLN injury.
Collapse
Affiliation(s)
- Andreas Moritz
- Department of Anesthesiology, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Joachim Schmidt
- Department of Anesthesiology, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Waldemar Schreiner
- Department of Thoracic Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anesthesiology, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Horia Sirbu
- Department of Thoracic Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Andrea Irouschek
- Department of Anesthesiology, University Hospital of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany
| |
Collapse
|
5
|
Hikage M, Kamei T, Nakano T, Abe S, Katsura K, Taniyama Y, Sakurai T, Teshima J, Ito S, Niizuma N, Okamoto H, Fukutomi T, Yamada M, Maruyama S, Ohuchi N. Impact of routine recurrent laryngeal nerve monitoring in prone esophagectomy with mediastinal lymph node dissection. Surg Endosc 2016; 31:2986-2996. [PMID: 27826777 DOI: 10.1007/s00464-016-5317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 10/25/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The problem of recurrent laryngeal nerve (RLN) paralysis (RLNP) after radical esophagectomy remains unresolved. Several studies have confirmed that intraoperative nerve monitoring (IONM) of the RLN during thyroid surgery substantially decreases the incidence of RLN damage. This study tried to determine the feasibility and effectiveness of IONM of the RLN during thoracoscopic esophagectomy in the prone position for esophageal cancer. METHODS All 108 patients who underwent prone esophagectomy at Tohoku University Hospital between July 2012 and March 2015 were included in this study. We divided patients into two groups: a control group (No-Monitoring group, surgery without IONM; n = 54) and a study group (Monitoring group, surgery with IONM; n = 54). In Monitoring group, neural stimulation was performed for both RLNs before and after dissection in the thoracic procedure, then for RLNs and vagus nerves (VNs) in the cervical procedure. The feasibility of IONM in Monitoring group and early surgical outcomes were retrospectively compared with those in No-Monitoring group. RESULTS IONM could be performed for 47 cases (87.0%) in Monitoring group. Reasons for discontinuation were use of muscle relaxants (3 patients), change in thoracotomy procedure (2 patients), past rib bone fracture (1 patient), and allergic shock by transfusion (1 patient). Right RLNPs were identified postoperatively in 4 patients, and left RLNPs in 23 patients. IONM sensitivities were 92.7 and 88.0% for the right and left VNs, respectively. Incidences of postoperative RLNP, aspiration, and primary pneumonia did not differ significantly between groups. CONCLUSIONS This study confirmed the feasibility and safety of IONM of the RLN for thoracoscopic esophagectomy in the prone position. No significant differences in postoperative outcomes were seen between esophagectomy with and without IONM.
Collapse
Affiliation(s)
- Makoto Hikage
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Takashi Kamei
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Toru Nakano
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeo Abe
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Kazunori Katsura
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yusuke Taniyama
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Tadashi Sakurai
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Jin Teshima
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Soichi Ito
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Nobuchika Niizuma
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Toshiaki Fukutomi
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masato Yamada
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shota Maruyama
- Department of Surgery, Division of Organ Transplantation, Reconstruction and Endoscopic Surgery, Tohoku University Hospital, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Noriaki Ohuchi
- Department of Surgical Oncology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| |
Collapse
|
6
|
Abstract
INTRODUCTION There have been several reports on the feasibility and curability of thoracoscopic esophagectomy, which may reduce injury to the thoracic cage and decrease the invasiveness of surgery. Although the recurrent laryngeal nerve (RLN) is identified and kept intact during operations, RLN palsy sometimes occurs. Currently, surgical aides, including intraoperative neurological monitoring, are being utilized to avoid RLN injury during thyroid surgery. This system is utilized during thoracoscopic esophagectomy in the prone position. PATIENTS AND METHODS Seven consecutive patients (six men, one woman; age range 62-74 years; mean 68 years) were included. Patients underwent general anesthesia and were intubated using the NIM TriVantage™ electromyography (EMG) tube. One-lung ventilation was performed with an endobronchial blocker. Thoracoscopic esophagectomy was performed in the prone position. The nerve stimulator was calibrated to 0.5 mA, and after the RLN was visually identified it was subsequently stimulated, which also confirmed normal machine functioning. In some situations, in the absence of a response, stimuli were increased to 1.0 mA and then 2.0 mA. RESULTS Intraoperatively, all seven patients had their nerve signals monitored. In one case, a nerve signal disappeared after complete lymph node dissection along the left RLN. This system could identify the site of injury, and the thoracoscopic magnified view allowed the disrupted point to be located precisely. When we checked VTR after surgery, the source of injury was one point tension of the nerve pulled by fiber during lymph node dissection. CONCLUSIONS Intraoperative RLN monitoring during thoracoscopic esophagectomy in the prone position, with one-lung ventilation performed using the TriVantage™ EMG tube and a bronchial blocker, is technically feasible, easy, and reliable.
Collapse
|
7
|
Schmidt J, Irouschek A, Heinrich S, Oster O, Klein P, Birkholz T. Recurrent laryngeal nerve monitoring during esophagectomy and mediastinal lymph node dissection: a novel approach using a single-lumen endotracheal EMG tube and the EZ-blocker. World J Surg 2013; 36:2946-7; author reply 2948. [PMID: 22736347 DOI: 10.1007/s00268-012-1700-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|