Ann Thorac Surg 2005;79:1886-1889
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Reconstruction of Recurrent Laryngeal Nerve With Involvement by Metastatic Node in Esophageal Cancer
Shoji Natsugoe, MD*,
Hiroshi Okumura, MD,
Masataka Matsumoto, MD,
Sumiya Ishigami, MD,
Tetsuhiro Owaki, MD,
Shizuo Nakano, MD,
Takashi Aikou, MD
Department of Surgical Oncology and Digestive Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
Accepted for publication November 24, 2004.
* Address reprint requests to Dr Natsugoe, First Department of Surgical Oncology and Digestive Surgery, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan (E-mail: natsugoe{at}m2.kufm.kagoshima-u.ac.jp).
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Abstract
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BACKGROUND: Recurrent laryngeal nerve paralysis represents one of the major complications in esophageal cancer surgery, and patients with esophageal cancer sometimes develop recurrent laryngeal nerve paralysis before treatment. We evaluated recurrent laryngeal nerve reconstruction in patients with lymph node metastasis infiltrating the recurrent laryngeal nerve.
METHODS: Five patients with preoperative recurrent laryngeal nerve paralysis as a result of involvement of metastasis were enrolled in the present study. Ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck was performed in 4 patients and direct anastomosis of recurrent laryngeal nerve in the mediastinum in 1 patient.
RESULTS: Six months after surgery, 3 patients who had undergone ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck displayed good quality of life without hoarseness or aspiration. The patient who underwent direct anastomosis of the recurrent laryngeal nerve in the mediastinum experienced occasional aspiration and hoarseness. The remaining patient displayed poor condition because of recurrent lung tumor, and quality of life was decreased.
CONCLUSIONS: If patients with recurrent laryngeal nerve paralysis before treatment can undergo potentially curative resection with lymph node dissection, including the metastatic lymph node infiltrating the recurrent laryngeal nerve, recurrent laryngeal nerve reconstruction should be performed to improve quality of life.
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Introduction
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Recurrent laryngeal nerve paralysis (RLNP) represents one of the major postoperative complications for patients with esophageal cancer. The incidence of RLNP after esophagectomy ranges from 14.0% to 45.3%, according to the grade of lymph node dissection [1–7]. Recurrent laryngeal nerve paralysis is particularly common in cases involving complete lymphadenectomy along the recurrent laryngeal nerve (RLN) [7]. However, some patients experience RLNP before treatment, and esophageal cancer is sometimes discovered on examination for symptoms of hoarseness and aspiration [8]. Recurrent laryngeal nerve lymph nodes are some of the most important nodes for metastasis from carcinoma of the upper and middle esophagus. In most such cases, the RLN is involved by lymph node metastasis. However, radical surgery using esophagectomy and resection of the metastatic lymph node infiltrating the RLN is applicable to some patients [9]. The present study examined reconstruction of the RLN in patients with RLNP before surgery as a result of involvement of the RLN by metastatic nodes. We demonstrated the surgical technique and results of RLN reconstruction.
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Patients and Methods
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Patients
Five patients with RLNP at the time of diagnosis of esophageal cancer were enrolled in the present study. All patients were male, with ages ranging from 42 to 69 years of age. Three patients displayed tumor in the upper third of the esophagus, whereas 2 demonstrated tumor in the middle third. All patients had advanced tumor (T3) with lymph node metastasis. Histologic type was well-differentiated squamous cell carcinoma in three lesions and moderately differentiated squamous cell carcinoma in two lesions. Tumor stage was stage III in 4 patients, and stage VI in 1 patient. All patients underwent macroscopically curative resection. Chemoradiotherapy was performed preoperatively in 3 patients, and postoperatively in 2 patients (Table 1). In all cases, RLNP was attributable to involvement of the RLN by metastatic nodes. Positions of lymph nodes involving the RLN were left RLN nodes in 2 patients, right cervical paraesophageal lymph node in 1 patient, left cervical paraesophageal lymph node in 1 patient, and left tracheobronchial lymph node in 1 patient. Although the first symptom was dysphagia in 3 patients and hoarseness in 2 patients, an otolaryngologist laryngoscopically diagnosed all patients with unilateral RLNP before surgery. Positions of lymph nodes involving the RLN node were identified in all patients using preoperative computed tomography or endoscopic ultrasonography.
Surgical Technique
Left and right ansa cervicalis-RLN anastomoses in the neck were performed in 3 patients and 1 patient, respectively. Direct anastomosis of the RLN in the mediastinum was performed in 1 patient (patient 4). Neurorrhaphy was undertaken using a loupe with 2.5-fold magnification. When the ansa cervicalis was used, this nerve was found and preserved anterior to the carotid artery and jugular vein. After trimming the edges of both the ansa cervicalis and RLN, end-to-end anastomosis was performed using two or three stitches with interrupted sutures of 7-0 or 8-0 polypropylene (Figs 1, 2).
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Results
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Anastomoses of the ansa cervicalis and RLN were performed successfully. Direct anastomosis of the RLN below the aortic arch in the mediastinum proved relatively difficult because of the deep visual field. End-to-end anastomosis was achieved using only two stitches in this case. All patients were interviewed concerning issues such as daily life and phonation 6 months postoperatively. We examined the vocal cord movement in 4 patients except for 1 dead patient by endoscopy between 6 months and 1 year after surgery (Fig 3). Vocal cord paralysis was improved in 3 patients (Table 2). Performance status was good in all except patient 5. As that patient had developed recurrent lung disease, his general condition was not good when climbing stairs, drinking, and eating. Occasional symptoms of RLNP such as aspiration and hoarseness were found in patient 4, who underwent direct anastomosis of the RLN. No symptoms of RLNP were found in the remaining patients. Although 1 patient died of lung metastases 8 months postoperatively, 4 patients returned to work (Table 1).
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Fig 3. Finding of vocal cord movement by endoscopy. Vocal cord movement was improved at the time of speech 1 year after surgery.
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Comment
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Recurrent laryngeal nerve paralysis is one of the most serious complications in esophageal cancer surgery. The decreases in quality of life associated with difficulty drinking and eating that occur with RLNP can result in postoperative malnutrition [3, 10, 11]. Pneumonia caused by aspiration as a result of RLNP is one potential cause of death in long-term survivors after esophageal cancer surgery [12, 13]. Patients with preoperative RLNP display the same situation as those with postoperative RLNP. In this series, 3 patients received preoperative chemoradiotherapy that was expected to assist improvement of RLNP, but complete response was not found in any of the metastatic lymph nodes that had involved the RLN.
The clinical usefulness of reconstruction of the RLN was demonstrated in surgery for thyroid cancer. Miyauchi and associates [14] reported that in 8 patients who underwent vagus nerve-recurrent nerve suture, ansa cervicalis-RLN suture, or simple neurorrhaphy, all patients recovered from hoarseness. Maximum phonation times of these patients were significantly longer than those of patients without nerve repair. Crumley [15] reported that quality of phonation after ansa cervicalis-RLN anastomosis was superior to that after polytetrafluoroethylene (Teflon) injection or Isshiki thyroplasty. In the present study, 3 patients with ansa cervicalis-RLN anastomosis displayed good phonation, whereas 1 patient who displayed poor general condition because of recurrent tumor did not. One patient (patient 4) with direct anastomosis of the recurrent nerve in the mediastinum displayed occasional symptoms of RLNP such as aspiration and hoarseness. In that patient, neurorrhaphy had been performed deep in the thoracic cavity. We recommend ansa cervicalis-RLN anastomosis in the neck, as the technique is simple and safe under a good field of view. This technique is also applicable to injury of the RLN at the time of lymph node dissection. Even if palliative surgery is planned, ansa cervicalis-RLN anastomosis may be tried for good quality of life by preventing aspiration and hoarseness. However, this method for palliative surgery should be assessed according to the prognosis of each patient in the future.
In conclusion, even if patients display RLNP as a result of metastatic nodes before treatment, the nodes involving the RLN should be removed if curable resection including the primary tumor can be achieved. In such cases, ansa cervicalis-RLN anastomosis should be performed to improve postoperative quality of life.
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Fig 2. The end-to-end anastomosis between ansa cervicalis and recurrent laryngeal nerve was performed using two or three stitches with interrupted sutures of 7-0 or 8-0 polypropylene.
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References
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Abstract
Introduction
