Protecting the Recurrent Laryngeal Nerve During Esophagectomy: Clinical Impact of Intraoperative Neurophysiological Monitoring

Recurrent laryngeal nerve (RLN) injury remains one of the most consequential complications of esophagectomy, driving vocal cord palsy, aspiration, and pneumonia. Monitoring techniques, signal interpretation, and the underlying clinical evidence for intraoperative neurophysiological monitoring (IONM) in this setting remain heterogeneous. Eleven studies encompassing 837 patients, including a historical control cohort of 44 patients, were identified through a structured search of PubMed, ScienceDirect, Semantic Scholar, and Google Scholar. Eight studies compared IONM against a non-monitored or historical control group; three were single-arm series evaluating predictive electromyographic parameters or surgical feasibility. Across the eight controlled studies, IONM was generally associated with lower postoperative RLN palsy rates, although findings varied by study design and statistical adjustment, ranging from 0% to 33.3% with monitoring versus 9.8% to nearly 59% without monitoring, with no monitoring-related complications reported in any series. Intermittent triggered electromyography provided point-in-time evoked laryngeal responses, whereas continuous vagal stimulation or spontaneous electromyographic surveillance, used in select series, enabled ongoing detection of signal changes during dissection. Despite this pattern, the underlying evidence is almost entirely retrospective, outcome definitions vary across studies, and three of the eleven reports were single-arm designs that cannot independently support comparative efficacy claims. Prospective, multicenter trials with standardized monitoring protocols and outcome reporting are needed before IONM can be regarded as a validated standard of care in esophagectomy, rather than a promising adjunct