European Journal of Cardio-thoracic Surgery 20 (2001) 705–711

www.elsevier.com/locate/ejcts

Vocal cord dysfunction after left lung resection for cancer

Marc Filaire a,*, Thierry Mom b, Stéphanie Laurent b, Yacouba Harouna a, Adel Naamee a,
Laurent Vallet c, Bernadette Normand d, Georges Escande a
a
Department of General and Thoracic Surgery, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
b
Department of Otolaryngology, Head and Neck Surgery, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
c
Department of Anesthesia, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
d
Department of Biostatistics, University of Auvergne, Clermont-Ferrand, France
Received 12 February 2001; received in revised form 10 May 2001; accepted 23 May 2001

Abstract
Objectives: To evaluate the prevalence, the impact-related postoperative complications and the risk factors of vocal cord dysfunction
(VCD) after left lung resection for cancer. Methods: From February 1996 to April 1999, a review of prospectively gathered data was
performed on 99 consecutive patients who underwent a pneumonectomy ðn ¼ 50Þ or a lobectomy ðn ¼ 49Þ with a mediastinal lymph node
dissection. A fiber optic laryngeal examination was performed preoperatively for all patients and within the first week postoperatively in
patients with symptom(s) or sign(s) of VCD or respiratory complications. Results: Thirty-one patients (31%) had a postoperative VCD
(group VCD) and 68 (68%) did not (group non-VCD). Mortality rate was 19% in group VCD and 9% in group non-VCD ðP ¼ 0:13Þ. Group
VCD patients developed more pulmonary complications ðP ¼ 0:014Þ and cardiac complications ðP , 0:001Þ compared to group non-VCD
patients. A higher rate of reintubation ðP ¼ 0:005Þ, pneumonia ðP ¼ 0:06Þ, arrhythmia ðP ¼ 0:002Þ, cardiac failure ðP , 0:001Þ was notice-
able in group VCD and may account for the higher rate of complications in this group. Using multivariate analysis, preoperative radiotherapy
ðP ¼ 0:001Þ and pneumonectomy ðP ¼ 0:008Þ were predictive of postoperative VCD. Hospital stay was 22 ^ 16 days in group VCD and
13 ^ 9 days in group non-VCD ðP , 0:002Þ. Conclusion: VCD is a frequent event that can lead to dramatic pulmonary complications. We
would recommend to track it and to treat it as early as possible. q 2001 Elsevier Science B.V. All rights reserved.
Keywords: Vocal cord dysfunction; Lung cancer; Postoperative complications

1. Introduction
Because of their anatomic location around the aortic arch,
left vagus nerve (VN) and recurrent laryngeal nerve (RLN)
can be invaded by intrathoracic malignant neoplasms. For the
same reason, these nerves can be severed during hilar lung
tumor resection or mediastinal lymph nodes dissection.
Lesion of these nerves results in left vocal cord dysfunction
(VCD), that in turn is responsible for variable degree of glot-
tic incompetence and swallowing disorders [1,2]. Respira-
tory consequences of these nerve dysfunctions can be life-
threatening in patients undergoing pulmonary resection who
have consequently limited pulmonary reserve. The incidence
of postsurgical VCD has been unequally investigated. In
thoracic surgery, where VCD is particularly deleterious,
due to life-threatening complications, a few studies are
currently available. Among these, the studies reported by
Yellin et al. [3] as well as those later reported by Massard
* Corresponding author. Tel.: 133-4-7375-1567; fax: 133-4-7375-1566.
E-mail address: mfilaire@chu-clermontferrand.fr (M. Filaire).
1010-7940/01/$ - see front matter q 2001 Elsevier Science B.V. All rights reserved.
PII: S 1010-794 0(01)00819-3
et al. [4] brought evidence that previous history of head and
neck surgery for cancer with total or partial laryngeal conser-
vation, so-called conservative surgery, increased the risk of
postoperative respiratory complications following lung
resection. In particular, aspiration enhanced difficulties to
clear secretions can induce pneumonia and finally respiratory
distress. Our purpose was to evaluate the prevalence of the
unilateral VCD after left lung resection for cancer and to
focus more particularly on the incidence and impact-related
postoperative complications. Our second goal was to identify
risk factors of VCD and relations between vocal cord posi-
tion, type of nervous lesion, and postoperative complications.
2. Patients and methods
2.1. Patient populations
From February 1996 to April 1999, 100 patients under-
went left lobectomies or pneumonectomies for non-small
cell lung cancer in our institution. All the patients were
considered operable according to the existing guidelines
706 M. Filaire et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 705–711
for pulmonary resections [5] and diagnosis of cancer was
obtained preoperatively or intraoperatively before resection.
Intraoperative findings in a patient with a functional contra-
indication for pneumonectomy have shown a microscopic
involvement of the end of the main bronchus. This patient
was excluded of the study because we performed a lobect-
omy with lymph nodes sampling but not a real lymphade-
nectomy as described below. The remaining 99 patients
composed our study group and were entered prospectively
in the clinical database. Twenty-seven patients received a
preoperative treatment with chemotherapy ðn ¼ 21Þ, radio-
therapy ðn ¼ 2Þ, or both chemotherapy and radiotherapy
ðn ¼ 4Þ. Among the six patients with preoperative radiother-
apy, three received a dose of 54 Gy after a previous left
lobectomy for cancer and three received a dose of 40 Gy
with a concomitant chemotherapy for stage IIIB disease.
2.2. Preoperative assessment
Complete history, physical examination, complete blood
cell count, biochemical profile, chest roentgenogram,
computed tomographic scan of chest, brain and upper abdo-
men, electrocardiography (ECG), routine pulmonary func-
tion tests, arterial blood gases, and fiber optic laryngeal
examination by an otoloryngologist composed the preopera-
tive assessment for all patients. Differential lung perfusion
scans were performed in pneumonectomy patients and in
lobectomy patients with marginal pulmonary function test.
2.3. Surgical procedure
Endotracheal intubation was performed with double
lumen tube with carinal spur for lobectomy, without carinal
spur for pneumonectomy (Rush-Pilling SA, 31460 Le Faget,
France). The size of the endotracheal tube was N835 to N837
for women and N839 to N841 for men. The surgical
approach was a lateral or a postero-lateral thoracotomy by
the fith intercostal space. For pneumonectomy, we usually
performed mediastinal lymph nodes dissection before the
lung resection in order to have a correct exposure of the
main bronchus. The inferior pulmonary, the para-esopha-
geal and the sub-carinal lymph nodes were excised after
division of the inferior pulmonary ligament and the poster-
ior mediastinal pleura. The sub-aortic lymph node compart-
ment was exposed by incising the mediastinal pleura behind
the phrenic nerve and laterally to the inferior aspect of the
horizontal arch of the aorta. The pleura was reflected and
mediastinal fat and nodes were gently dissected. Hemostasis
in the sub-aortic area was performed with surgical clips and
we never used electric coagulation. The VN or RLN were
deliberately resected if they could not be dissected free from
the tumor or because there were in too close contact with
macroscopically invaded nodes. Adequate en bloc resection
of this node-bearing area provides us with a direct visuali-
zation of the pericardium, the horizontal arch of the aorta,
the pulmonary artery, the carina, and the esophagus.
2.4. Assessment of vocal cord dysfunction and postoperative
course
After tracheal extubation, monitoring of laryngeal func-
tion was made with a particular attention. A fiber optic
laryngeal examination was performed in case of hoarseness,
aspiration, ineffective cough, dysphagia, or pneumonia.
VCD was considered if the left vocal cord was paralyzed.
It could be abducted (extremely lateralized), intermediate
(3–4 mm from midline) or paramediane (1–2 mm from
midline). Patients with VCD compose the group VCD and
patients without VCD the group non-VCD.
Mortality was defined as death occurring within 30 days
of surgery or beyond that period if the patient had not left
the hospital. Postoperative complications (Cpo) were clas-
sified into pulmonary complications (PCpo), cardiac
complications (CCpo) and other complications (OCpo).
Pulmonary complications were defined as pneumonia
(temperature .388C for 48 h, purulent sputum production
and infiltrate on chest roentgenogram), lobar atelectasis,
postoperative bronchoscopy for atelectasis or major sputum
production, pulmonary embolus, non-cardiac pulmonary
edema, mechanical ventilation .48 h, reintubation, and
tracheostomy. Cardiac complications were defined as
myocardial ischemia, arrhythmia and cardiac failure (need
of inotrop drug infusion). Other complications were defined
as empyema, bronchopleural fistula, bleeding, and general
complications. Hospital stay was defined as the number of
days in the hospital after surgery.
2.5. Statistical analysis
The comparison between preoperative data, surgical
resection, pathologic finding and postoperative course of
group VCD and group non-VCD was carried out by
means of the Mann–Whitney test for continuous variables
and a Chi-square test for categoric variables. When the
expected value was ,5, the Fisher’s exact test was used.
Multivariate analysis by partition of Chi-square using
PCSM statistical package (Delta Consultants, Meylan,
France) was applied to determine whether qualitative vari-
ables were predictive of VCD. Parameters with a P , 0:1 at
the Chi-square test were selected to be entered into the
partition model. Briefly, with the partition of the Chi-square,
the selected and supposed explanatory variables are graded.
Finally, the eligible variables are independently associated
with the occurrence of VCD. A probability below 0.05 was
accepted as statistically significant.
3. Results
3.1. Study population
Pneumonectomy was performed in 50 patients and
lobectomy in 49. VCD occurred in 31 patients (31%)
whom composed the group VCD. Preoperative VCD was
 M. Filaire et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 705–711 707

observed in three patients because of VN invasion by the
tumor in two cases and RLN injury during mediastinoscopy
in the latter case. In 15 patients, VCD was due to deliberate
resection of the intrathoracic segment of the nerve that was
invaded or too close to the tumor to be preserved. Thirteen
patients had an unexpected VCD despite surgical nerve
preservation. The remaining 68 patients with normal laryn-
geal motility composed the group non-VCD. The character-
istics of the VCD and non-VCD groups are given in Table 1
with a comparison between the two.
3.2. Incidence and risk factors
Using a Chi-square test, risk factors of postoperative
VCD were found to be the following: preoperative radio-
therapy ðP ¼ 0:039Þ, pneumonectomy ðP ¼ 0:007Þ and
pericardiotomy ðP ¼ 0:009Þ. In contrast, preoperative
chemotherapy ðP ¼ 0:083Þ, sub-aortic lymph node(s) larger
than 1 cm on the CT scan ðP ¼ 0:14Þ, sub-aortic N2 disease
ðP ¼ 0:11Þ, and TNM staging [6] ðP ¼ 0:58Þ were not
predictive of VCD. Using multivariate analysis, preopera-
tive radiotherapy ðP ¼ 0:001Þ and pneumonectomy ðP ¼
0:008Þ were found to be independent and predictive factors
of VCD. Details on risk factors of postoperative VCD are
shown in Table 1.
3.3. Symptoms
Hoarseness occurred in all patients with VCD, aspiration
in 11 (35%), poor cough in eight (25%) (need of a broncho-
scopy for major sputum production), and dysphagia in two
(6.5%). A bronchoscopy for inefficient cough was necessary
in 54% of the patients who had aspiration compared to 15%
of the patients who did not ðP ¼ 0:025Þ. Thirty-six percent
of the patients who had aspiration developed pneumonia
compared to 10% of the patients who did not ðP ¼ 0:088Þ.
3.4. Mortality and morbidity
Mortality was 12% in our study, but it was not statisti-
cally different between groups VCD and non-VCD
ðP ¼ 0:13Þ. Table 2 shows the prevalence of mortality in
each group and the cause of death.
Group VCD patients developed more pulmonary compli-
cations ðP ¼ 0:014Þ and CCpo ðP , 0:001Þ compared to
group non-VCD patients. A higher rate of reintubation
ðP ¼ 0:005Þ, arrhythmia ðP ¼ 0:002Þ, cardiac failure ðP ¼
0:003Þ was noticeable in group VCD and may account for
the higher prevalence of complications in this group.
However, the higher prevalence of pneumonia in group
VCD was not statistically significant ðP ¼ 0:06Þ. A compar-
ison of morbidity between the group VCD and group non-
VCD is given in Table 3. Hospital stay was increased in
group VCD (mean 22 ^ 16 days, range 8–78) compared
with group non-VCD (mean 13 ^ 9 days, range 7–57)
ðP ¼ 0:002Þ.
In group VCD, sex, age, absolute and predictive values of
forced vital capacity (FVC), forced expiratory volume in 1 s
(FEV1), postoperative predictive forced expiratory volume
in 1 s (FEV1ppo), and type of resection were similar
between patients with PCpo and others. However, among
PCpo patients, those who needed reintubation had lower
FVC and percent of predicted forced vital capacity

Table 1
Comparison of preoperative characteristics, surgical procedures, and pathologic finding between the group VCD and the group non-VCD a

Group VCD ðn ¼ 31Þ Group VCD vs. group Group non-VCD ðn ¼ 68Þ
non-VCD (P-value)

Sex 26 males, 5 females 0.85 58 males, 10 females

Age (years) 62 ^ 8 0.26 60 ^ 10
FEV1 (L) 2.410 ^ 0.76 0.77 2.450 ^ 0.74
FEV% 82.3 ^ 20.9 0.50 79.3 ^ 19.7
FVC (L) 3.42 ^ 1.03 0.28 3.63 ^ 0.94
FVC% 91 ^ 22.2 0.56 93 ^ 17.6
FEV1ppo (L) 1.69 ^ 0.49 0.15 1.87 ^ 0.58
FEV1ppo% 58.2 ^ 16.1 0.24 60.8 ^ 16.3
Previous surgery for head and neck cancer 4 0.055 1
Preoperative chemotherapy 10/28 b 0.083 13/68
Preoperative radiotherapy 4/28 b 0.01 c 1/68
Lymph node .1 cm on CT scan 9/28 b 0.14 11/68
Pneumonectomy 21/28 b 0.007 c 27/68
Pericardiotomy 10/28 b 0.009 7/68
Pathology 20 SC, nine A, two others b 0.68 38 SC, 23 A, seven others
TNM 3 Ia, 3 Ib, 3 IIa, 4 IIb, 6 IIIa, 0.58 12 Ia,13 Ib, 5 IIa, 14 IIb, 13 IIIa, 9 IIIb,
7 IIIb, 2 IV b 2 IV
N2 disease 8/28 b 0.11 10/68
a
Values of age and pulmonary function data are mean ^ standard deviation. SC, squamous cell carcinoma; A, adenocarcinoma; FEV1ppo%, percent of
predicted postoperative predictive forced expiratory volume in 1 s.
b
Three patients with preoperative VCD has been excluded of the group VCD in order to test risk factors of the occurrence of acute postoperative VCD.
c
P , 0:01 using multivariate analysis by partition of Chi-square.
708 M. Filaire et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 705–711

Table 2
Mortality and causes of death in the groups VCD and non-VCD

Patients Mortality Causes of death

No. %

Group VCD 6/31 19 Two pneumonias, one mesenteric embolus, one brain stroke, one intestinal obstruction, one broncho-pleural fistula
Group non-VCD 6/68 9 One pneumonia, three postpneumonectomy edemas, one brain stroke, one broncho-arterial fistula

(%FVC) than patients who needed no reintubation
(P ¼ 0:014 and P ¼ 0:022, respectively). None of the
other types of PCpo previously defined were found to be
significant risk factors of VCD.
We also compared mortality and morbidity between
pneumonectomy patients of the two groups. Pneumonect-
omy patients of the group VCD ðn ¼ 21Þ needed more rein-
tubations ðP ¼ 0:044Þ, and developed more aspirations
ðP ¼ 0:0003Þ and cardiac failure ðP ¼ 0:027Þ compared to
the pneumonectomy patients of the non-VCD group
ðn ¼ 27Þ. The higher prevalence of postoperative bronchos-
copies ðP ¼ 0:065Þ, PCpo ðP ¼ 0:064Þ, CCpo ðP ¼ 0:064Þ
and mortality ðP ¼ 0:42Þ among pneumonectomy patients
of the VCD group were not statistically significant.
3.5. Relations between nerve injury, vocal cord position,
and morbidity
This analysis only concerned 28 patients of group VCD,
i.e. patients who had no preoperative VCD in order to
consider only patients with acute postoperative VCD. The
relationship between vocal cord position and nerve injury
are shown in Table 4. Note that an abducted position of the
vocal cord was found in the vast majority of cases (87%) of
RLN or VN section. Forty-seven percent of the patients with
an abducted vocal cord needed a postoperative broncho-
scopy compared to 9% of patients with intermediate or
paramediane vocal cord position ðP ¼ 0:032Þ. In contrast,
patients with an abducted vocal cord did not have signifi-
cantly more aspiration ðP ¼ 0:89Þ, pneumonia ðP ¼ 0:61Þ,
reintubation ðP ¼ 0:25Þ, lobar atelectasis ðP ¼ 0:85Þ or
PCpo ðP ¼ 0:25Þ than the rest of the 29 patients.
4. Discussion
The main results of this study are that VCD
† occurs in one-third of the patients after left lung resection
and mediastinal lymph nodes dissection for cancer,
† is associated with a higher rate of morbidity with a higher
rate of reintubation and arrhythmia,
† occurs more frequently in patients who received preo-
perative radiotherapy or who underwent pneumonect-
omy.
It is clear that lung surgery for cancer is not a rare cause of
VCD. In a retrospective study based on 280 patients with
unilateral vocal fold immobility, Benninger et al. [7] found
that 24% of the patients were secondary to extra laryngeal
malignancies, 80% of which were due to pulmonary or
mediastinal disease. In 1029 patients reviewed from the
literature, Terris et al. [8] found that 20% of cases of
VCD were associated with lung cancer. Undoubtedly, one
of the most frequent extra laryngeal causes of VCD is repre-
sented by intrathoracic malignancies and in particular, lung
cancer. However, to date, the prevalence of postoperative

Table 3
Comparison of morbidity between the group VCD and the group non-VCD a

Group VCD ðn ¼ 31Þ Group VCD vs. group Group non-VCD ðn ¼ 68Þ
non-VCD (P-value)
No. % No. %

Pneumonia 7 22 0.06 6 9
Aspiration 11 38 , 0.001 0 0
Atelectasis 5 16 0.28 6 9
MV$48 h 7 22 0.06 6 9
Reintubation 7 22 0.001 2 3
Postoperative bronchoscopy 10 32 0.10 12 18
Total of PCpo 16 51 0.014 18 26
Arrhythmia 11 35 0.002 7 10
Cardiac failure 7 22 , 0.001 0 0
Total of CCpo 12 39 , 0.001 7 10
OCpo 7 22 0.06 6 9
Total of Cpo 19 61 0.022 25 36
a
MV, mechanical ventilation; PCpo, postoperative pulmonary complications; CCpo, postoperative cardiac complications; OCpo, others postoperative compli-
cations; Cpo, postoperative complications.
 M. Filaire et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 705–711
Table 4
Position of the vocal cord related to the type of nervous injury in patients
with acute postoperative VCD
Position of the vocal Section of VN or RLN Respect of the nerve
cord ðn ¼ 16Þ ðn ¼ 12Þ
Abduction 14 6
Intermediate 1 1
Paramediane 1 3
Residual mobility 0 2
VCD has been unequally investigated. For example, after
patent ductus arteriosus ligation, Zbar et al. [9] have
reported a prevalence of only 7.4% of vocal cord paralysis
with no improvement after an average follow-up of 6
months. After carotid endarteriectomy, Curran et al. [10]
found a 20% prevalence of VCD, which was transient in
90% of the cases. In a retrospective study of 1026 patients
undergoing thyroid gland surgery, Wagner et al. [11] found
that VCD occurred in 5.9% of the cases. Surprisingly, our
results show that left lung resection for cancer is associated
with a higher prevalence of VCD compared with other
cervical or thoracic surgical procedure for benign patholo-
gies.
VCD was the result of the surgical section of VN or RLN
in 58% of our patients with VCD. In these cases, the nerves
could not be dissected free from the tumor because of a
direct tumor or lymphatic invasion of the sub-aortic region.
In the remaining 42% of the cases, VCD was unexpected
because the nerve was thought to be preserved. It is impor-
tant to note that we never used electric coagulation but
surgical clips for hemostasis during lymph nodes dissection.
Therefore, one can exclude various degrees of heat-related
nerve injury. Firstly, VN and RLN may have been stretched
during hilar tumor dissection of the aortic window resulting
in neuropraxia. Secondly, injury to these nerves could be
due to the damage of the perineural vasculature. Indeed,
perineural vascular injury is considered by some authors
as a cause of RLN paralysis after thyroidectomy [12]. In a
recent anatomic study, we showed that branches arising
from the anterior broncho-esophageal artery were a constant
blood supply to the sub-aortic segment of VN and the origin
of RLN. Therefore, nervous ischemia during sub-aortic
lymph node excision is likely to occur and could explain
postoperative VCD [13]. Thirdly, anatomic studies have
shown that the anterior terminal branch, designated as the
motor branch, is located laterally, whose position makes it
particularly exposed to surgical wound or trauma [14]. From
our point of view, there is no doubt that this lateral position
of the motor fibers within the nerve can give account of the
postoperative VCD, even though the nerve was anatomi-
cally preserved.
In our study, it is more interesting that in case of nervous
section, 83% of patients had an abducted vocal cord. In
contrast, when the nerves were thought to be preserved,
we only noted an abducted vocal cord in 50% of cases.
709
For us, these results suggest that the respiratory function
of the RLN, mediated by the fibers directed to the cricoar-
ythenoid muscle (the only muscle dilatator of the glottis) is
more sensitive to surgical injury than the phonatory fibers
directed to the glottal constrictors. Because anastomotic
networks are often found between the superior laryngeal
nerve (SLN) and RLN, within the interarythenoid muscle,
or within the thyroarythenoid muscle [15], the position of
the impaired vocal cord could depends upon the develop-
ment of these networks. Thus, even though these constrictor
muscles are deprived of RLN fibers, they can still be
connected with other motor fibers arising from SLN, allow-
ing for persistent capacity of adduction motility.
Whereas an abducted vocal cord was associated with less
efficient cough, we did not observe a significant increase of
pneumonia in these cases. It is likely that pneumonia could
be avoided by postoperative bronchoscopy. Further, it is not
surprising that the vocal cord position was not correlated
with aspiration. Indeed, it is clear that aspiration depends
upon multiple causes such as a glottal protection by the
epiglottis or the performance of the sensitive innervation
of the larynx, for instance. Because swallowing depends
on the integrity of both motor and sensitive innervation, it
is likely that swallowing disorders are more frequently
mentioned after both lesions of RLN and SLN than after
unilateral RLN paralysis alone [16].
Hoarseness is reported to occur in 86–100% of patients
after surgical RLN paralysis [1,17,18]. In our study, all
patients with VCD had hoarseness likely because the
contralateral vocal cord was unable to immediately compen-
sate the laryngeal paralysis. In 45% of the patients, hoarse-
ness was the only one symptom of VCD. Thus, in cases of
hoarseness, a laryngeal examination should be rapidly
realized to confirm the diagnosis of VCD and to prevent
its consequences. Aspiration must be tracked, inasmuch as
it can be asymptomatic [17] because it can result in sudden
choking, gradual bronchial obstruction, and pneumonia,
which are dramatic complications, more likely to occur in
patients with less efficient cough and impaired pulmonary
function. This was particularly well shown by Henderson et
al. [2]. In 15 patients with VCD caused by bronchogenic
carcinoma, these authors found that 73% had aspiration.
Similarly in 111 patients with VCD and after esophageal
cancer surgery, Hirano et al. [18] found that 53% had aspira-
tion, most often associated with a weak cough. Eighty four
percent of these patients developed pneumonia and 47%
needed a tracheostomy. In our study, the 35% prevalence
of aspiration in patients with VCD is low and probably
underestimated because we only recorded symptomatic
aspiration.
In our study, VCD did not have a significant influence on
mortality. As a matter of fact, in both groups, the most
frequent cause of death was not the consequence of VCD.
Yet, let us remark that two of the three patients who died of
pneumonia had VCD.
The lack of airway protection resulting from laryngeal
710 M. Filaire et al. / European Journal of Cardio-thoracic Surgery 20 (2001) 705–711
dysfunction can be associated with respiratory complica-
tions. This was evident in our studies where postoperative
pulmonary complications occurred in 51% of the patients
with VCD but in only 26% of the others. Others authors
have also reported that laryngeal dysfunction increases
morbidity after thoracic surgery. Massard et al. [4] have
undoubtedly pointed out an increased risk of respiratory
complications due to aspiration, following lung surgery in
patients with previous history of voice sparing surgery for
pharyngo-laryngeal malignancy (23%) compared to patients
with total laryngectomy. Hirano et al. [18] have reported a
rate of 45% of aspiration pneumonia in patients with VCD
caused by esophageal cancer surgery. By contrast, respira-
tory complications caused by VCD are very uncommon
after surgery of the carotid artery, thyroid gland, and ductus
arteriosus in young patients [9–11]. These results show that
patients undergoing lung or esophageal surgery for cancer
are at high risk of postoperative complications in case of
VCD. Undoubtedly, one of the main reasons of increased
risk of VCD-related pulmonary complication, is due to the
reduction of air flow and vital capacity after lung resection
[19]. This characteristic, which is specific to thoracic
surgery, jeopardizes the ability to generate an efficient
cough and to clear secretions and aspirations. Impaired
ventilation, dyspnea, and increased respiratory work may
generate fatigue of respiratory muscles in patients with
lowest ventilatory reserve. This problem may be crucial
after pneumonectomy. Thus, it was not surprising, in our
study, that patients with VCD differed significantly from
patients without VCD by a higher rate of reintubation.
Among patients with VCD, those who needed reintubation
had a restrictive pattern at the preoperative pulmonary func-
tion tests. Finally,the major cause of reintubation was
respiratory muscle fatigue resulting from bronchial obstruc-
tion by sputum and weak cough in four patients (57%).
Little is known about the responsibility of VN or LRN
section in the occurrence of arrhythmia after thoracic opera-
tions. Numerous risk factors of arrhythmia including atrial
inflammation, pericarditis, pulmonary hypertension, hypox-
emia, cardiac failure, deranged hemodynamics caused by
valvular diseases, and increased vagal or sympathetic tone
can exist [20]. Because the heart is innervated by both
sympathetic and parasympathetic nerves that form the
cardiac plexus located under the aortic arch, one can
hypothesize that injury to the VN and RLN predispose to
arrhythmia.
In a large retrospective study, Asamura et al. [21] found
that RLN or VN section was not predictive of arrhythmia. In
our study, univariate analysis showed that the occurrence of
VCD was a risk factor of arrhythmia as well as pericardiot-
omy and cardiac failure but that the extent of the resection
was not. A multivariable analysis of these four variables
revealed that the occurrence of a cardiac failure (need of
inotrop drug) was the only one significant risk factor. Also,
we observed that preoperative cardiac events were present
in 66% of our patients with arrhythmia compared to 40% in
patient without arrhythmia ðP , 0:045Þ. If injury to VN and
RLN results in an imbalance between sympathetic and para-
sympathetic tones, it may influence arrhythmia like other
risk factors mentioned previously. Therefore, for us, the
preoperative cardiac status is the more important factor to
consider in order to predict arrhythmia.
The VN or RLN are at high risk of injury during dissec-
tion of the sub-aortic region. Our report shows that the risk
was considerably increased in case of preoperative radio-
therapy or pneumonectomy. In both situations, the identifi-
cation and the respect of the nerve were more difficult and
sometimes impossible because of tissue fibrosis after radio-
therapy or because of their close proximity to the tumors in
case of pneumonectomy. In contrast, the size and the inva-
sion of the sub-aortic lymph nodes were not associated with
a higher rate of VN or RLN injury.
In conclusion, our study brings additional evidence that
VCD after left lung resection for cancer is a frequent event
that can lead to dramatic pulmonary complications. Right
RLN injury may also occur following right lung cancer
resection with extensive lymph node dissection up to the
sub-clavian artery. It would be ideal to avoid RLN and
VN injury, and in this aim, intraoperative evoked laryngeal
monitoring is promising [22]. Lastly, since VCD can be a
highly deleterious event, we would recommend to track it
and to treat it as early as possible in such patients just
operated for lung cancer.
Acknowledgements
We thank Mrs Martine Collomb for her help in the
preparation of the manuscript.
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