Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 28, 2020; 26(12): 1340-1351
Published online Mar 28, 2020. doi: 10.3748/wjg.v26.i12.1340
Novel technique for lymphadenectomy along left recurrent laryngeal nerve during thoracoscopic esophagectomy
Wen-Shu Chen, Li-Huan Zhu, Wu-Jin Li, Peng-Jie Tu, Jian-Yuan Huang, Pei-Lin You, Xiao-Jie Pan
Wen-Shu Chen, Li-Huan Zhu, Wu-Jin Li, Peng-Jie Tu, Jian-Yuan Huang, Pei-Lin You, Xiao-Jie Pan, Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian Province, China
Author contributions: Chen WS and Pan XJ conception and design of the study; Chen WS, Zhu LH, Li WJ and Pan XJ performed the experiments; Huang JY, Tu PJ and You PL analyzed data; Wen-Shu Chen WS and Zhu LH wrote the paper.
Institutional review board statement: The study was reviewed and approved by the institutional review board and the Ethics Committee of Fujian Provincial Hospital (#K2019-06-028).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Wen-Shu Chen, MD, Associate Professor, Chief Doctor, Surgeon, Surgical Oncologist, Department of Thoracic Surgery, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No. 134 East Street, Fuzhou 350001, Fujian Province, China. doctorcws@163.com
Received: November 9, 2019
Peer-review started: November 9, 2010
First decision: December 23, 2019
Revised: February 27, 2020
Accepted: March 9, 2020
Article in press: March 9, 2020
Published online: March 28, 2020
Processing time: 139 Days and 21.2 Hours
Abstract
BACKGROUND

In esophageal squamous carcinoma, lymphadenectomy along the left recurrent laryngeal nerve (RLN) is recommended owing to its highly metastatic potential. However, this procedure is difficult due to limited working space in the left upper mediastinum, and increases postoperative complications.

AIM

To present a novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position.

METHODS

The fundamental concept of this novel method is to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane, which includes the left RLN, lymph nodes (LNs) along the left RLN, and tracheoesophageal vessels, by suspending the esophagus to the dorsal side and pushing the trachea to the ventral side (named “bilateral exposure method”). Then, the hollow-out method is performed to transform the two-dimensional membrane to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels are easily distinguished and preserved during lymphadenectomy along the left RLN. This novel method was retrospectively evaluated in 116 consecutive patients with esophageal squamous carcinoma from August 2016 to February 2018.

RESULTS

There were 58 patients in each group. No significant difference was found between the two groups in terms of age, gender, postoperative pneumonia, anastomotic fistula, and postoperative hospitalization. However, the number of dissected LNs along the left RLN in this novel method was significantly higher than that in the conventional method (4.17 ± 0.359 vs 2.93 ± 0.463, P = 0.0447). Moreover, the operative time and the rate of postoperative hoarseness in the novel method were significantly lower than those in the conventional method (306.0 ± 6.774 vs 335.2 ± 7.750, P = 0.0054; 4/58 vs 12/58, P = 0.0312).

CONCLUSION

This novel method for lymphadenectomy along the left RLN during thoracoscopic esophagectomy in the semi-prone position is much safer and more effective.

Keywords: Bilateral pedicled nerve flap; Bilateral exposure method; Hollow-out method; Left recurrent laryngeal nerve; Lymphadenectomy; Thoracoscopic esophagectomy

Core tip: Lymph nodes (LNs) along recurrent laryngeal nerves (RLNs) are highly involved in esophageal carcinoma. Due to limited working space in the superior mediastinum, lymphadenectomy along RLNs is very difficult, especially the left RLN. Our study provides a novel method for lymphadenectomy along the left RLN. The fundamental concept of this novel method was to exfoliate a bilateral pedicled nerve flap, which is a two-dimensional membrane that includes the left RLN, surrounding LNs, and tracheoesophageal vessels. Then, the hollow-out method was performed to transform it to a three-dimensional structure, in which the left RLN and tracheoesophageal vessels could be easily distinguished and preserved during lymphadenectomy. Compared with the conventional method, this novel method not only increased the number of dissected LNs, but also shortened the operative time and reduced the rate of postoperative hoarseness.