Recurrent laryngeal nerve paralysis as a potential mediator of complications in esophagectomy following lymph node dissection

Complications from esophagectomy often interact with each other, with those related to recurrent laryngeal nerve (RLN) paralysis (RLNP) being particularly significant. Aggressive dissection of RLN lymph nodes (RLN-LNs) is considered a major contributing factor to RLNP. This study seeks to validate the hypothesis that RLNP acts as a mediator, not only resulting from RLN-LN dissection but also amplifying the likelihood of other postoperative complications. Data were retrospectively extracted from the Chinese 12th Five-Year Major Science and Technology Project on esophageal diseases, including a cohort of 1684 patients enrolled between 2015 and 2018. Both univariate and multivariate structural equation models were employed to validate the mediating role of RLNP in postoperative complications. Without causing RLNP, RLN-LN dissection directly increased the risk of chylothorax (odds ratio [OR] = 1.179, 95% confidence interval [CI] = 1.003-1.385) and decreased the risk of cardiac arrhythmia (OR = 0.919, 95% CI = 0.838-0.993). Meanwhile, through the mediating effect of RLNP, RLN-LN dissection indirectly led to complications requiring intensive care (OR = 1.043, 95% CI = 1.004-1.083) and conservative therapy (OR = 1.043, 95% CI = 0.996-1.092). RLNP serves as a critical mediator between RLN-LN dissection and subsequent postoperative complications requiring intensive care and conservative therapy. Recognizing that many of these complications are mediated by RLNP could help thoracic surgeons prioritize neural protection during RLN-LN dissection, potentially reducing the overall risk of multiple complications and alleviating the associated concerns.