Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position

Abstract

Chylothorax is a serious complication of transthoracic esophagectomy. Intraoperative thoracic duct (TD) identification represents a possible tool for preventing or repairing its lesions, and it is most of the time difficult, even during high-definition thoracoscopy. The aim of the study is to demonstrate the feasibility of using near-infrared fluorescence-guided thoracoscopy to identify TD anatomy and check its intraoperative lesions during minimally invasive esophagectomy. A 0.5 mg/kg solution of indocyanine green (ICG) was injected percutaneously in the inguinal nodes of 19 patients undergoing minimally invasive esophagectomy in a prone position, before thoracoscopy. TD anatomy and potential intraoperative lesions were checked with the KARL STORZ OPAL1® Technology. In all of the 19 patients where transthoracic esophagectomy was feasible, the TD was clearly identified after a mean of 52.7 minutes from injection time. The TD was cut for oncological radicality in two patients, and it was successfully ligated under the ICG guide. No postoperative chylothorax or adverse reactions from the ICG injection occurred. The TD identification with indocyanine green fluorescence during minimally invasive esophagectomy is a simple, effective, and non-time-demanding tool; it may become a standard procedure to prevent postoperative chylothorax.

Fluorescence‐guided cancer surgery—A new paradigm

“…In a series of 19 patients undergoing minimally invasive esophagectomy, Vecchiato et al 70 reported successful real‐time identification of the TD. Following injection of 0.5 mg/kg of ICG percutaneously in the inguinal nodes, the authors were able to identify the TD after a mean period of 52.7 min from the time of injection.…”

RAMIE: tradition drives innovation—feasibility of a robotic-assisted intra-thoracic anastomosis

“…Esophagectomy is conducted through the dissection plan of the meso-esophagus, including the thoracic duct in the en bloc resection. Identification of the duct is facilitated using the robotic nearly-infrared camera (Firefly, Intuitive surgical, USA) after injecting indocyanine green in the inguinal lymph nodes at the end of the abdominal phase [8].…”

Fluorescent lymphography for thoracic duct identification: Initial experience of a simplified and feasible ICG administration

“…When injected subcutaneously ICG strongly binds to serum protein (alfa1‐lipoprotein), then it is rapidly absorbed and transferred to the lymphatic vessels 4 . Vecchiato et al 5 . illustrated an ICG administration protocol for the TD identification by near infrared fluorescence in oesophageal surgery.…”

“…When injected subcutaneously ICG strongly binds to serum protein (alfa1-lipoprotein), then it is rapidly absorbed and transferred to the lymphatic vessels. 4 Vecchiato et al 5 illustrated an ICG administration protocol for the TD identification by near infrared fluorescence in oesophageal surgery. In order to make the procedure safe, the injection of ICG into the inguinal nodes is ultrasound-guided, so the structures near the inguinal nodes can be visualised clearly and easily avoided.…”