BACKGROUND: We thought that using electrocautery for hemostasis caused recurrent laryngeal nerve palsy. We reflected the prolonged use of electrocautery and employed NU-KNIT® to achieve hemostasis nearby the recurrent laryngeal nerve. We assessed that using NU-KNIT® hemostasis prevented or not postoperative recurrent laryngeal nerve palsy, retrospectively. The present study was evaluated to compare using electrocautery hemostasis with using NU-KNIT® hemostasis during lymphadenectomy along recurrent laryngeal nerve. The variables compared were morbidity rate of recurrent laryngeal nerve palsy, operation time, and blood loss. RESULTS: We use NU-KNIT® to achieve hemostasis without strong compression. This group is named group N. On the other hand, we use electrocautery to achieve hemostasis. This group is named group E. Complication rate of recurrent laryngeal nerve palsy was higher in group E (55.6%) than group N (5.3%) (p = 0.007). CONCLUSIONS: Even hemostasis using NU-KNIT® was slightly more time-consuming than using electrocautery, we concluded that it would be useful to prevent recurrent laryngeal nerve palsy

Hiroshi Tamagawa

Munetaka Masuda

Naoto Yamamoto

Norio Yukawa

Shinichi Hasegawa

Takaki Yoshikawa

Takashi Oshima

Toshio Imada

Tsutomu Sato

Yasushi Rino

BMC Research Notes

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Rino et al. BMC Research Notes 2014, 7:127
http://www.biomedcentral.com/1756-0500/7/127RESEARCH ARTICLE Open AccessUsing NU-KNIT® for hemostasis around recurrent
laryngeal nerve during transthoracic
esophagectomy with lymphadenectomy for
esophageal cancer
Yasushi Rino1*, Norio Yukawa1, Tsutomu Sato1, Naoto Yamamoto1, Hiroshi Tamagawa1, Shinichi Hasegawa1,
Takashi Oshima2, Takaki Yoshikawa3, Munetaka Masuda1 and Toshio Imada4Abstract
Background: We thought that using electrocautery for hemostasis caused recurrent laryngeal nerve palsy. We
reflected the prolonged use of electrocautery and employed NU-KNIT® to achieve hemostasis nearby the recurrent
laryngeal nerve. We assessed that using NU-KNIT® hemostasis prevented or not postoperative recurrent laryngeal
nerve palsy, retrospectively. The present study was evaluated to compare using electrocautery hemostasis with
using NU-KNIT® hemostasis during lymphadenectomy along recurrent laryngeal nerve. The variables compared were
morbidity rate of recurrent laryngeal nerve palsy, operation time, and blood loss.
Results: We use NU-KNIT® to achieve hemostasis without strong compression. This group is named group N. On
the other hand, we use electrocautery to achieve hemostasis. This group is named group E. Complication rate of
recurrent laryngeal nerve palsy was higher in group E (55.6%) than group N (5.3%) (p = 0.007).
Conclusions: Even hemostasis using NU-KNIT® was slightly more time-consuming than using electrocautery, we
concluded that it would be useful to prevent recurrent laryngeal nerve palsy.Background
Surgery for transthoracic esophagectomy with lymphad-
enectomy is still associated with high complication rates
of recurrent laryngeal nerve palsy [1,2] and a long-
standing negative impact on the patient’s quality of life
(QOL). In our institute, the rate of recurrent laryngeal
nerve palsy was 13.3% after esophagectomy with lymph-
adenectomy for thoracic esophageal cancer until June
2008. Because of the high rate of #106 rec R and L
lymph nodes with cancer involvement, complete lymph-
adenectomy along bilateral recurrent laryngeal nerve is
desirable, but it often cause recurrent laryngeal nerve
palsy leading dysphagia or aspiration pneumonia. Thus,
reducing the risk of such complications could reduce the
negative impact on QOL after esophageal cancer sur-
gery. Electrocautery is a safe and effective method of* Correspondence: rino@med.yokohama-cu.ac.jp
1Department of Surgery, Yokohama City University, Yokohama, Japan
Full list of author information is available at the end of the article
© 2014 Rino et al.; licensee BioMed Central Lt
Commons Attribution License (http://creativec
reproduction in any medium, provided the or
Dedication waiver (http://creativecommons.or
unless otherwise stated.hemostasis during esophageal cancer surgery. There are
no absolute contraindications to electrosurgery. Each elec-
trocautery device can deliver heat at a single temperature
or range of temperatures, between 100°C and 1200°C. We
assumed that the temperature using electrocautery for
hemostasis caused recurrent laryngeal nerve palsy and
reflected the prolonged use of electrocautery and
employed NU-KNIT® [3,4], in January 2010, to get
hemostasis nearby the recurrent laryngeal nerve. NU-
KNIT® has 3 times more dense than SURGICEL® Original
Absorbable Hemostat >36% faster time to hemostasis.
Dense knit material provides strength in the presence of
heavy bleeding. NU-KNIT® is soft, pliable weave designed
to hold a suture and for placement on delicate tissue [3,4].
Indications of SURGICEL is that haemostat is used
adjunctively in surgical procedures to assist in the control
of capillary, venous, and small arterial haemorrhage when
ligation or other conventional methods of control are
impractical or ineffective [4]. We assessed that using
NU-KNIT® hemostasis prevented or not postoperatived. This is an Open Access article distributed under the terms of the Creative
ommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
iginal work is properly credited. The Creative Commons Public Domain
g/publicdomain/zero/1.0/) applies to the data made available in this article,
Rino et al. BMC Research Notes 2014, 7:127 Page 2 of 4
http://www.biomedcentral.com/1756-0500/7/127recurrent laryngeal nerve palsy, retrospectively. The
present study was evaluated to compare using electro-
cautery hemostasis with using NU-KNIT® hemostasis
during lymphadenectomy along recurrent laryngeal
nerve. The variables compared were morbidity rate of
recurrent laryngeal nerve palsy, operation time, and
blood loss.
Methods
The patients were candidates for an esophagectomy at
our institute from July 2008 to August 2011. The pa-
tients are consecutive and non-selected. This study was
performed with the approval of an appropriate ethics
committee. Informed consent was obtained from all
patients to use NU-KNIT for this study according to
the institutional rules of the Yokohama City University
Hospital. The study protocol conforms to the ethical
guidelines of the 1975 declaration of Helsinki as reflected
in a priori approval by the institution’s human research
committee.
Between January 2010 and August 2011, we use NU-
KNIT® to achieve hemostasis without strong compres-
sion. This group is named group N (mean age: 67.6 years;
age range: 56–76 years; 18 men, 1 woman). On the other
hand, except the preceding period, we use electrocautery
to achieve hemostasis. This group is named group E
(mean age: 65.2 years; age range: 49–75 years; 8 men,
1 woman) (Table 1).
All esophagectomy with lymphadenectomy were per-
formed by same surgeon.
We investigated the rate of recurrent laryngeal nerve
palsy, operation time, and blood loss in patients who
underwent esophagectomy with lymphadenectomy, retro-
spectively. Recurrent laryngeal nerve palsy was diagnosed
by otolaryngologists.
Statistical analysis was conducted using Student’s t-test
and χ2 test with P < 0.05 taken as significant.
Results
The results are summarized in the Table 1. In group E,
five of 9 cases (55.6%) were complicated recurrent laryn-
geal nerve palsy. Two of 5 recurrent laryngeal nerve
palsy cases were bilateral. Four of 5 recurrent laryngeal
nerve palsy patient in group E were reversible. Mean
blood loss was 584.2 ml. Mean operation time was
521.9 min and mean thoracotomy time was 200.0 min.
In group N, one of 19 cases (5.3%) was complicated re-
current laryngeal nerve palsy. There is no bilateral re-
current laryngeal nerve palsy. Mean blood loss was
834.2 ml. Mean operation time was 541.9 min and
mean thoracotomy time was 258.0 min. Three of 11
cases were lost blood more than 1,000 ml with injured
spleen. Mean blood loss was 482.3 ml except for the
three cases. There were no significant difference betweentwo groups in the incidence of complications; blood loss,
and operation time. But the incidence of complication of
recurrent laryngeal nerve palsy was significantly higher in
group E (55.6%) than group N (5.3%) (p = 0.007).
Discussion
In our institute, the rate of recurrent laryngeal nerve palsy
was 13.3% after esophagectomy with lymphadenectomy
for thoracic esophageal cancer until June 2008. Okuyama
et al. reported that they compared the outcomes of cer-
vical hand-sewn anastomosis and intrathoracic stapled
anastomosis performed after esophagectomy and gastric
reconstruction. The respective rates of recurrent laryngeal
nerve palsy were 38.8% versus 7.1% (P < 0.05) [1]. Fang
et al. reported that patients in the three-field lymphade-
nectomy experienced significantly more recurrent laryn-
geal nerve palsy than the two-field lymphadenectomy
(22.9% vs. 9.6%, P = 0.089) [2]. The rates of recurrent
laryngeal nerve palsy after esophagectomy are still high.
Sometimes the time to achievement of adequate hemostasis
using electrocautery was prolonged. Cauterization using
electrocautery is superior to suture as a method of achiev-
ing hemostasis, with significantly less blood loss and
shorter operative time [5]. Parenchymatous hemostasis
using electrocautery greased with lidocaine gel was easy to
perform and achieved complete hemostasis of the minor
blood vessels in all patients. No postoperative bleeding oc-
curred and the follow-up course was satisfactory. Electro-
cautery greased with lidocaine gel is an inexpensive, readily
available, and efficient method to achieve hemostasis of
minor vessels in hepatic, splenic, and bone operations
[6]. However, electrocautery can deliver heat at a single
temperature or range of temperatures, between 100°C
and 1200°C. Physicians must consider the histologic
properties of the tissue to be treated, the area and
depth of destruction desired, possible recurrent laryn-
geal nerve palsy after esophagectomy. We assumed that
the temperature using electrocautery for hemostasis
caused recurrent laryngeal nerve palsy and employed NU-
KNIT® [3,4]. The use of NU-KNIT® as buttress material
may be effective in reducing acute postoperative bleeding
in laparoscopic Roux-en-Y gastric bypass at a significantly
lower cost [7]. Surgicel NU-KNIT® for the sternum bleed-
ing permitted a good hemostatic effect without wax use
[3,8]. Despite the probe of electrocautery is not used to
achieve hemostasis around recurrent laryngeal or vagus
nerve, complication rate of recurrent laryngeal nerve palsy
was so high. We guessed that prolonged electrosurgical
hemostasis time affected the nerve. We quit using electro-
cautery near the nerve to prevent recurrent laryngeal
nerve palsy. Since January 2010, we have employed
NU-KNIT® to achieve hemostasis without press the
nerve. We successfully performed an esophagectomy
with lymphadenectomy in 11 esophageal cancer patients
Table 1 Patients characters and operation datas
Hemostasis Sex Age pTNM stage Blood Operation time/ Recurrent nerve
methods (M/F) (y/o) loss (ml) thoracotomy time (min) palsy (y/n)
Group E M 75 pT1bN0M0 I 1249 703/286 y (bilateral)
M 67 pT3N1M0 III 1343 500/186 n
M 64 pT3N0M0 II 669 503/198 y
M 57 pT1bN0M0 III 389 518/212 y (bilateral)
M 49 pT4N0M1 IVb 200 379/153 n
M 51 pT3N1M0 III 100 395/210 n
M 60 pT1bN1M0 II 500 476/160 y
M 61 pT3N2M0 III 600 502/235 y
F 57 pT3N0M0 II 208 640/160 n
Average ± S.D. 60.1 ± 8.0 584.2 ± 446.4 512.9 ± 103.6/200.0 ± 42.5 Complication rate; 55.6%*
Group N M 63 pT2N1M0 II 795 594/220 n
M 61 pT2N0M0 II 3000 660/240 y
M 67 pT3N0M1 IVb 555 429/190 n
M 66 pT1aN0M0 0 500 499/170 n
M 68 pT3N1M0 III 691 590/235 n
M 66 pT2N2M0 III 2140 513/199 n
M 64 pT3N0M0 II 250 545/264 n
M 70 pT1aN0M0 0 765 558/281 n
M 76 pT2N0M0 II 2992 472/239 n
M 63 pT1bN0M0 I 788 623/353 n
M 72 pT3N1M0 III 278 466/202 n
M 74 pT1bN0M0 I 300 561/324 n
F 74 pT2N0M0 II 675 355/236 n
M 56 pT3N2M0 III 100 435/195 n
M 74 pT1aN0M0 0 319 541/284 n
M 63 pT1bN0M0 I 400 508/272 n
M 69 pT3N1M0 III 757 621/273 n
M 75 pT1bN0M0 I 341 708/374 n
M 63 pT1bN0M0 I 203 618/351 n
Average ± S.D 67.6 ± 5.6 834.2 ± 877.9 541.9 ± 88.0/258.0 ± 59.3 Complication rate; 5.3%
Group E; using electrocautery to achieve hemostasis, Group N; using NU-KNIT® to achieve hemostasis.
M; male, F; female, S.D.; standard deviation, *; p = 0.007.
Rino et al. BMC Research Notes 2014, 7:127 Page 3 of 4
http://www.biomedcentral.com/1756-0500/7/127using NU-KNIT® from January 2010 to December 2010.
One of 11 cases complicated recurrent laryngeal nerve
palsy. This case has lymph node adhesion to left recurrent
laryngeal nerve. Even the left recurrent laryngeal nerve
was preserved using scissors, the palsy remained.
NU-KNIT® has 3 times more dense than SURGICEL®
Original Absorbable Hemostat >36% faster time to
hemostasis. Dense knit material provides strength in the
presence of heavy bleeding. NU-KNIT® is soft, pliable
weave designed to hold a suture and for placement on
delicate tissue [3,4]. Because of these characters of NU-
KNIT®, we employed it to hemostasis near the nerve.
Blood loss and operation time were increased than usingelectrocautery to hemostasis, but there were no signifi-
cant difference. Thoracotomy time was also prolonged,
but there were no significant difference, as well.Conclusions
Hemostasis using NU-KNIT® can be good strategy to
prevent recurrent laryngeal nerve palsy in transthoracic
esophagectomy. But more cases are needed to evaluate a
confident prevention of recurrent laryngeal nerve palsy.Abbreviations
QOL: Quality of life; NAC: Neoadjuvant chemotherapy.
Rino et al. BMC Research Notes 2014, 7:127 Page 4 of 4
http://www.biomedcentral.com/1756-0500/7/127Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors carried out these procedures. YR wrote the manuscript. OT
participated in paper revise. All authors read and approved the final
manuscript.
Author details
1Department of Surgery, Yokohama City University, Yokohama, Japan.
2Gastroenterological Center, Medical Center, Yokohama City University,
Yokohama, Japan. 3Department of Gastrointestinal Surgery, Kanagawa Cancer
Center, Yokohama, Japan. 4Saiseikai Yokohama Nanbu Hospital, Yokohama,
Japan.
Received: 30 October 2013 Accepted: 26 February 2014
Published: 6 March 2014
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doi:10.1186/1756-0500-7-127
Cite this article as: Rino et al.: Using NU-KNIT® for hemostasis around
recurrent laryngeal nerve during transthoracic esophagectomy
with lymphadenectomy for esophageal cancer. BMC Research Notes
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Using NU-KNIT® for hemostasis around recurrent laryngeal nerve during transthoracic esophagectomy with lymphadenectomy for esophageal cancer

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Using NU-KNIT® for hemostasis around recurrent laryngeal nerve during transthoracic esophagectomy with lymphadenectomy for esophageal cancer

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