Short- And Long-Term Outcomes of Recurrent Palsy (Rlnp) After Esophagectomy: 10-Year Experience in a High-Volume Center

Background Recurrent laryngeal nerve palsy (RLNP) is a serious complication after esophagectomy that can cause aspiration, pneumonia, and voice changes. The impact of RLNP on long-term oncologic outcomes remains unclear, especially since RLNP often occurs in cases requiring extensive surgery for advanced tumors. We examined short-term postoperative outcomes and long-term oncologic outcomes in a 10-year experience at a high-volume center to determine the effect of RLNP. Methods All patients undergoing esophagectomy between April 2015 and February 2025 at University Medical Center Mainz were retrospectively reviewed. We experienced only cases of unilateral RLNP (no bilateral palsies), with RLNP confirmed by routine pre- and postoperative laryngoscopy. Postoperative complications (e.g., pneumonia and anastomotic leak) and long-term outcomes (recurrence, overall survival) were compared between patients with and without RLNP. We performed propensity score matching (1:2) on key covariates (patient factors, tumor characteristics, treatment) to adjust for baseline differences. Results A total of 845 patients were analyzed; 50 (5.9%) had RLNP. Patients with RLNP had higher rates of pneumonia (28% vs. 18%) and anastomotic leak (22% vs. 12%) compared to those without RLNP. Tumor recurrence rates were similar (32% vs. 30%). RLNP was associated with lower 3-year recurrence-free survival (HR 1.64, 95% CI 1.03–2.60, p = 0.038) and overall survival (HR 1.82, 95% CI 1.04–3.17, p = 0.035). After matching for tumor stage and other factors, survival (HR 1.28, p = 0.459) and recurrence-free survival differences (HR 1.17, p = 0.598) were no longer significant, indicating convergence of survival curves. Conclusion Unilateral RLNP significantly increases short-term morbidity (pneumonia and anastomotic leak) without compromising a 90-days mortality as well as hospital stay but does not adversely affect long-term oncologic outcomes. The observed survival disadvantage in patients with RLNP is attributable to more advanced tumor burden rather than the nerve injury itself. Thus, the risk of RLNP should not prompt surgeons to reduce oncologic radicality during esophagectomy. Our 10-year single-center series provides robust evidence for these findings, especially given that randomized trials are unfeasible and multi-center studies may introduce heterogeneity.