Prognostic impact of recurrent laryngeal nerve palsy after esophagectomy: a systematic review and reconstructed individual patient data meta-analysis.

BACKGROUND: Multimodal therapy with esophagectomy and lymphadenectomy remains the cornerstone of treatment for esophageal cancer. The incidence of recurrent laryngeal nerve (RLN) lymph node metastasis in thoracic esophageal carcinoma ranges from 30% to 50%. Previous studies reported that RLN lymphadenectomy may improve survival; however, surgical dissection may increase the risk for RLN palsy (RLNP). The prognostic effect of RLNP is debated with studies reporting conflicting results. The purpose of the present study was to investigate the influence of RLNP on long-term survival in patients undergoing esophagectomy for cancer. METHODS: A reconstructed individual patient data (IPD) meta-analysis was performed using restricted mean survival time difference (RMSTD) estimation. PubMed, Scopus, Web of Science, ClinicalTrials.gov, Cochrane Central Library, and Google Scholar databases were searched through December 15th, 2025. Overall survival (OS) was primary outcome. RMSTD, time dependent hazard ratio (HR), risk ratio (RR), standardized mean difference (SMD), and 95% confidence interval (CI) were used as pooled effect size measures. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was employed to evaluate the certainty of evidence. PROSPERO CRD420261287613. RESULTS: The analysis included 2,115 patients (five retrospective studies) undergoing esophagectomy. RLNP was reported in 24.4%. Patients' ages ranged from 56 to 75 years and 69% were males. Squamous cell carcinoma (SCC) was diagnosed in 96.3%. McKeown esophagectomy was performed in 90.8%. At 5-year follow-up, the multivariate meta-analysis showed similar OS for RLNP vs. no RLNP (-0.21 months; 95% CI: -2.4, 2.7). No significant differences were found regarding mortality hazard up to 60-month follow-up (HR =0.96; 95% CI: 0.79, 1.10). RLNP was associated with a significantly higher risk for pneumonia (RR =1.82), pulmonary complications (RR =1.94), reintubation (RR =3.83), and anastomotic leak (RR =1.52). CONCLUSIONS: In this reconstructed Kaplan-Meier-based IPD meta-analysis of retrospective studies, RLNP after esophagectomy was not associated with a detectable difference in long-term OS. Because of relevant confounders, the available evidence does not allow exclusion of an independent prognostic effect of RLNP. RLNP was associated with increased risks of pneumonia, reintubation, pulmonary complications, and anastomotic leak.