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Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery

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Abstract

Purpose

Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye.

Methods

Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker’s 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina.

Results

In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30–330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident.

Conclusions

Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

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Data Availability

The data is available with the corresponding author and can be shared upon a suitable request.

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Authors and Affiliations

  1. Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India

    Subramanyeshwar R. Thammineedi, Sujit C. Patnaik, Pratap Reddy, Srijan Shukla & Syed Nusrath

  2. Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia

    Yogesh K. Vashist

Authors
  1. Subramanyeshwar R. Thammineedi
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  2. Sujit C. Patnaik
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  3. Pratap Reddy
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  5. Yogesh K. Vashist
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Contributions

SR—acquisition of data, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript. SP—acquisition of data, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript. SS—study conception and design, drafting of manuscript, critical revision of manuscript. PR—drafting of manuscript, critical revision of manuscript. YV—interpretation of data, drafting of manuscript, critical revision of manuscript. SN—study conception and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical revision of manuscript.

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Correspondence to Syed Nusrath.

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Thammineedi, S.R., Patnaik, S.C., Reddy, P. et al. Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery. Langenbecks Arch Surg 408, 426 (2023). https://doi.org/10.1007/s00423-023-03162-2

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