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

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.