Awake Nebulized Indocyanine Green (ICG) for Tracheobronchial Fluorescence: A Safety and Feasibility Study in...

Indocyanine green (ICG) imaging has shown potential in improving minimally invasive esophagectomy (MIE) safety in many ways. However, the risk of tracheobronchial tree injury remains a major concern. Real-time ICG-guided tracheobronchial fluorescence (TBF) is an innovative application of this technology for preventing such injuries. This study aimed to evaluate the feasibility and safety of nebulized ICG administered using an affordable nebulizer during the awake position to achieve TBF during the single-lung ventilation phase of MIE. An observational study was conducted on 30 consecutive patients undergoing McKeown's MIE. A compressor-type nebulizer was used to administer 5 ml (2.5 mg/ml) of aerosolized ICG before anesthesia induction. The real-time TBF was assessed with a near-infrared imaging system during the thoracic phase. All 30 patients had locally advanced squamous cell carcinoma and received neoadjuvant therapy. Of these, 21 (70%) had tumors in the middle third. Median time for nebulization was 9 min (8-11), and the time interval between this and the first TBF visualization was 90 min (80-150). TBF visualization was achieved in 30/30 (100%) and persisted throughout the thoracic phase in all (100%). No intraoperative tracheobronchial injury or ICG allergy was observed. Grade 3 or 4 pulmonary complications occurred in 13.3% of cases. Administering nebulized ICG while awake results in effective real-time TBF during MIE, improving surgical precision and safety. This simple, affordable, and reliable method shows promise for decreasing airway-related complications and improving outcomes in esophageal cancer surgery.