Routine Intraoperative Fluorescence Lymphography Using Indocyanine Green During Esophagectomy: A Feasibility Study

For resectable esophageal cancer, major oncological centers recommend a transthoracic esophagectomy with an en-bloc mediastinal lymphadenectomy that includes resection of the thoracic duct. However, thoracic duct resection may increase the risk of postoperative chyle leakage because of injury to the main duct, collaterals, or side branches. Intraoperative, real-time fluorescence lymphography using indocyanine green (ICG) has emerged as a promising technique to enhance visualization of the thoracic duct, side branches, and collaterals during esophagectomy. This study aims to investigate the feasibility of routine fluorescence lymphography with ICG during esophagectomy for cancer to accurately visualize the thoracic duct and its collaterals. For fluorescence lymphography, 2 mL of ICG solution (2.5 mg ICG/mL) is administered bilaterally in the inguinal lymph nodes, before the thoracic phase of esophagectomy, or into the small bowel mesenteric root shortly before abdominal closure. A near-infrared (NIR) camera is used to assess fluorescence lymphography. Under fluorescence visualization, the thoracic duct is double-clipped distally at the level of the arch of the azygos vein and clipped proximally 4-5 cm above the level of the diaphragm and transected en bloc with the esophagectomy specimen. Additional clipping or suture ligation is performed in case of chyle leakage of the main duct or any remaining collateral ducts/side branches. Fluorescence lymphography was performed in 20 patients undergoing esophagectomy for esophageal cancer. The thoracic duct was successfully visualized in 18 patients (90%). In 67% of patients in whom successful fluorescence lymphography was performed, this led to a change of management, for example, the placement of extra clips. Fluorescence lymphography with ICG helps visualize the thoracic duct and its collaterals and identify chyle leakage intraoperatively, which often results in a change in operative management. Further development of the study is needed to refine the technique and confirm its application in preventing postoperative chyle leakage.