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 cervical 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) . Fang et al. reported that patients in the three-field lymphadenectomy experienced significantly more recurrent laryngeal nerve palsy than the two-field lymphadenectomy (22.9% vs. 9.6%, P = 0.089) . 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 achieving hemostasis, with significantly less blood loss and shorter operative time . 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 occurred and the follow-up course was satisfactory. Electrocautery greased with lidocaine gel is an inexpensive, readily available, and efficient method to achieve hemostasis of minor vessels in hepatic, splenic, and bone operations . 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 laryngeal 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 . Surgicel NU-KNIT® for the sternum bleeding 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 electrocautery 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 using 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 using electrocautery to hemostasis, but there were no significant difference. Thoracotomy time was also prolonged, but there were no significant difference, as well.