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Zhu X, Feng X, Huang Z, Xu W, Guo A, Xu J, Chen Z, Shen T, Zhou J, He Z. Analysis of related factors and treatment effect of chylothorax after lung surgery. J Thorac Dis 2024; 16:3291-3305. [PMID: 38883668 PMCID: PMC11170394 DOI: 10.21037/jtd-24-692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Abstract
Background Chylothorax is a seldom encountered complication following lung surgery. However, due to the widespread practice of lung surgery, postoperative complications have inevitably arisen. Chylothorax significantly affects a patient's discharge and recovery. This study investigates the risk factors for postoperative chylothorax at our center and analyzes various treatment modalities and prognostic outcomes. Methods A retrospective analysis was conducted on all postoperative lung resections performed between January 2018 to August 2021 that met the inclusion criteria. Inclusion criteria covered patients undergoing various thoracic surgeries for lung conditions, while exclusion criteria included postoperative referrals for surgeries unrelated to lung tumors. Results Postoperative chylothorax occurred in 42 of 5,706 patients after lung surgery. General information and disease-related data of the chylothorax and control group were analyzed by univariate and multivariate analyses. Multivariate analysis showed that serum albumin before surgery [odds ratio (OR) =0.86, 95% confidence interval (CI): 0.81-0.91, P<0.001], γ-glutamyl transferase level before surgery (after logarithmic transformation, OR =1.01, 95% CI: 1.00-1.01, P=0.01), squamous cell carcinoma (OR =2.77, 95% CI: 1.37-5.6, P=0.008), right mediastinal lymph node dissection (OR =3.15, 95% CI: 1.62-6.14, P<0.001) were independent risk factors for postoperative chylothorax. Among the 42 cases of postoperative chylothorax, 26 patients were improved with conservative treatments, and 6 patients were improved with chemical pleurodesis. Eight patients with postoperative chylothorax underwent thoracoscopic thoracic duct ligation. Three patients experienced severe postoperative complications: one was discharged after prolonged treatment, while the remaining two either succumbed or were discharged against medical advice. Conclusions The incidence of chylothorax after lung surgery closely correlates with the intraoperative trauma and nutritional status of patients during the perioperative period. The majority of patients with postoperative chylothorax experienced relief through conservative measures, somatostatin administration, and chemical pleurodesis. Nevertheless, substantial postoperative chylothorax necessitated surgical intervention, involving thoracic duct ligation or drug pleurodesis.
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Affiliation(s)
- Xingyu Zhu
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiangwei Feng
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhengwei Huang
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wangjue Xu
- Department of Thoracic Surgery, Longyou People's Hospital, Quzhou, China
| | - Aotian Guo
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingwei Xu
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhao Chen
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Shen
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiayu Zhou
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhengfu He
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Mahmoodzadeh H, Farahzadi A, Omranipour R, Harirchi I, Jalaeefar A, Shirkhoda M, Miri SR, Hadjilooei F. Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy. Cancer Rep (Hoboken) 2024; 7:e2053. [PMID: 38577849 PMCID: PMC10995935 DOI: 10.1002/cnr2.2053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.
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Affiliation(s)
- Habibollah Mahmoodzadeh
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Athena Farahzadi
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Ramesh Omranipour
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Iraj Harirchi
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Amirmohsen Jalaeefar
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Mohammad Shirkhoda
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Seyed Rouhollah Miri
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
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Thammineedi SR, Patnaik SC, Reddy P, Shukla S, Vashist YK, Nusrath S. Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery. Langenbecks Arch Surg 2023; 408:426. [PMID: 37917238 DOI: 10.1007/s00423-023-03162-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
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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Affiliation(s)
- Subramanyeshwar R Thammineedi
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Sujit C Patnaik
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Pratap Reddy
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Srijan Shukla
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Yogesh K Vashist
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India.
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Komatsuzaki S, Hisakura K, Ogawa K, Akashi Y, Kim J, Moue S, Miyazaki Y, Furuya K, Doi M, Owada Y, Shimomura O, Ohara Y, Takahashi K, Hashimoto S, Enomoto T, Koike N, Oda T. Transhiatal bilateral thoracic duct ligation for duplicated thoracic duct injury after esophagectomy: a case report. Surg Case Rep 2022; 8:213. [DOI: 10.1186/s40792-022-01567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
Background
The treatment of duplicated thoracic ducts (TDs) injury after esophagectomy generally requires a bilateral transthoracic approach. We present the cases of two patients with postoperative chylothorax who underwent transhiatal bilateral TD ligation for duplicated TDs.
Case presentation
Two patients diagnosed with chylothorax after esophagectomy performed for thoracic esophageal cancer underwent transhiatal TD ligation. Although supradiaphragmatic mass ligation was performed on the fat tissue of the right side of the aorta containing the TD, chyle leakage persisted. To tackle this, the fat tissue of the left side of the aorta was ligated, after which the chyle leakage stopped.
Conclusion
Compared to the conventional transthoracic approach, the transhiatal approach enables the ligation of both left- and right-sided TD in a single surgical operation, without the need to change the patient’s posture. This approach may be appropriate for the treatment of chylothorax after esophagectomy, considering the possibility of duplicated TDs.
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Shao C, Li Z, Zhang C, Zhang W, He R, Cai Y, Xu J. Optical diagnostic imaging and therapy for thyroid cancer. Mater Today Bio 2022; 17:100441. [PMID: 36388462 PMCID: PMC9640994 DOI: 10.1016/j.mtbio.2022.100441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022]
Abstract
Thyroid cancer, as one of the most common endocrine cancers, has seen a surge in incidence in recent years. This is most likely due to the lack of specificity and accuracy of its traditional diagnostic modalities, leading to the overdiagnosis of thyroid nodules. Although there are several treatment options available, they are limited to surgery and 131I radiation therapy that come with significant side effects and hence cannot meet the treatment needs of anaplastic thyroid carcinoma with very high malignancy. Optical imaging that utilizes optical absorption, refraction and scattering properties, not only observes the structure and function of cells, tissues, organs, or even the whole organism to assist in diagnosis, but can also be used to perform optical therapy to achieve targeted non-invasive and precise treatment of thyroid cancer. These applications of screening, diagnosis, and treatment, lend to optical imaging's promising potential within the realm of thyroid cancer surgical navigation. Over the past decade, research on optical imaging in the diagnosis and treatment of thyroid cancer has been growing year by year, but no comprehensive review on this topic has been published. Here, we review key advances in the application of optical imaging in the diagnosis and treatment of thyroid cancer and discuss the challenges and potential for clinical translation of this technology.
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Géczi T, Simonka Z, Lantos J, Wetzel M, Szabó Z, Lázár G, Furák J. Near-infrared fluorescence guided surgery: State of the evidence from a health technology assessment perspective. Front Surg 2022; 9:919739. [PMID: 35959120 PMCID: PMC9360526 DOI: 10.3389/fsurg.2022.919739] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Different applications of near-infrared fluorescence-guided surgery are very promising, and techniques that help surgeons in intraoperative guidance have been developed, thereby bridging the gap between preoperative imaging and intraoperative visualization and palpation. Thus, these techniques are advantageous in terms of being faster, safer, less invasive, and cheaper. There are a few fluorescent dyes available, but the most commonly used dye is indocyanine green. It can be used in its natural form, but different nanocapsulated and targeted modifications are possible, making this dye more stable and specific. A new active tumor-targeting strategy is the conjugation of indocyanine green nanoparticles with antibodies, making this dye targeted and highly selective to various tumor proteins. In this mini-review, we discuss the application of near-infrared fluorescence-guided techniques in thoracic surgery. During lung surgery, it can help find small, non-palpable, or additional tumor nodules, it is also useful for finding the sentinel lymph node and identifying the proper intersegmental plane for segmentectomies. Furthermore, it can help visualize the thoracic duct, smaller bullae of the lung, phrenic nerve, or pleural nodules. We summarize current applications and provide a framework for future applications and development.
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Affiliation(s)
- Tibor Géczi
- Department of Surgery, Faculty of Medicine, University of Szeged, Szeged, Hungary
- Correspondence: Tibor Géczi
| | - Zsolt Simonka
- Department of Surgery, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Judit Lantos
- Department of Neurology, Bács-Kiskun County Hospital, Kecskemét, Hungary
| | - Melinda Wetzel
- Department of Anesthesiology, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szabó
- Institute of Surgical Research, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - György Lázár
- Department of Surgery, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - József Furák
- Department of Surgery, Faculty of Medicine, University of Szeged, Szeged, Hungary
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7
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Tamburini N, Chiozza M, Maniscalco P, Resta G, Marino S, Quarantotto F, Anania G, Cavallesco G. Application of Indocyanine Green Enhanced Fluorescence in Esophageal Surgery: A Mini Review. Front Surg 2022; 9:961856. [PMID: 35874138 PMCID: PMC9304659 DOI: 10.3389/fsurg.2022.961856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Despite recent technological innovations and the development of minimally invasive surgery, esophagectomy remains an operation burdened with severe postoperative complications. Fluorescence imaging, particularly using indocyanine green (ICG), offers the ability to address a number of issues faced during esophagectomy. The three main indications for the intraoperative use of ICG during esophagectomy are visualization of conduit vascular supply, allow identification of sentinel nodes and visualization of the thoracic duct. The purpose of this mini review is to present an overview of current practice in fluorescence imaging utilizing ICG during esophagectomy, as well as to demonstrate how this technology can guide lymphadenectomy and reduce surgical morbidity such as anastomotic leaking and chylothorax.
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Barnes TG, MacGregor T, Sgromo B, Maynard ND, Gillies RS. Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy. Surg Endosc 2021; 36:5319-5325. [PMID: 34905086 PMCID: PMC9160097 DOI: 10.1007/s00464-021-08912-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022]
Abstract
Background Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy.
Methods Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak.
Results 20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct. Conclusion This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery. Clinical trial registration Clinical trials.gov (NCT03292757).
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Affiliation(s)
- Thomas G Barnes
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Thomas MacGregor
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bruno Sgromo
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas D Maynard
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard S Gillies
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Chen L, Lin L, Li L, Xie Z, He H, Lin C, Chen J, Lin A. Lymphatic leakage after pelvic lymphadenectomy for cervical cancer: a retrospective case-control study. BMC Cancer 2021; 21:1242. [PMID: 34794409 PMCID: PMC8603468 DOI: 10.1186/s12885-021-08984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 11/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The study aims to evaluate the clinical features and management of postoperative lymphatic leakage (PLL) in patients with cervical cancer who received pelvic lymphadenectomy. METHODS This retrospective study screened consecutive patients with cervical cancer (stage Ia2-IIb). RESULTS Among 3427 cases screened, 63 patients (1.8%) were diagnosed with PLL, which manifested as persistent abdominal drainage (42/63, 66.7%), chylous ascites (12/63, 19.0%) or vaginal drainage (9/63, 14.3%). Median time from surgery to onset of PLL was 6 days (range, 4-21 days). All cases resolved in a median 10 days (range, 3-56 days) after conservative treatment; although one case experienced recurrence of vaginal drainage after 26 days, this also resolved after conservative therapy. Multivariate analysis showed that two cycles of neoadjuvant chemotherapy (odds ratio [OR], 3.283; 95% confidence interval [95%CI], 1.289-8.360; P = 0.013), a decrease in hemoglobin level of ≥20 and < 30 g/L (OR, 6.175; 95%CI, 1.033-10.919; P = 0.046) or ≥ 30 g/L (OR, 8.467; 95%CI, 1.248-17.426; P = 0.029), and postoperative albumin level ≥ 30 and < 35 g/L (OR, 2.552; 95%CI, 1.112-5.857; P = 0.027) or < 30 g/L (OR, 5.517; 95%CI, 2.047-18.148; P = 0.012) were associated with PLL. CONCLUSION Neoadjuvant chemotherapy, postoperative anemia and postoperative hypoproteinemia are risk factors for PLL.
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Affiliation(s)
- Li Chen
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Liang Lin
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Ling Li
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Zuolian Xie
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Haixin He
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Cuibo Lin
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - Jian Chen
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China
| | - An Lin
- Department of Gynecology, Fujian Medical University Cancer Hospital, Fujian Cancer Hospital, Fuzhou, 350014, Fujian, China.
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Yang YH, Park SY, Kim DJ. Chyle Leakage after Esophageal Cancer Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:191-199. [PMID: 32793451 PMCID: PMC7409880 DOI: 10.5090/kjtcs.2020.53.4.191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
Surgeons recommend dissecting lymph nodes in the thorax, abdomen, and neck during surgery for esophageal cancer because of the possibility of metastasis to the lymph nodes in those areas through the lymphatic plexus of the esophageal submucosal layer. Extensive lymph node dissection is essential for accurate staging and is thought to improve survival. However, it can result in several complications, including chyle leakage, which refers to continuous lymphatic fluid leakage and can occur in the thorax, abdomen, and neck. Malnutrition, fluid imbalance, and immune compromise may result from chyle leakage, which can be potentially life-threatening if it persists. Therefore, various treatment methods, including conservative treatment, pharmacological treatment such as octreotide infusion, and interventions such as thoracic duct embolization and surgical thoracic duct ligation, have been applied. In this article, the risk factors, diagnosis, and treatment methods of chyle leakage after esophagectomy are reviewed.
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Affiliation(s)
- Young Ho Yang
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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Matsuura Y, Ichinose J, Nakao M, Okumura S, Mun M. Recent fluorescence imaging technology applications of indocyanine green in general thoracic surgery. Surg Today 2019; 50:1332-1342. [PMID: 31664525 DOI: 10.1007/s00595-019-01906-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/20/2019] [Indexed: 12/19/2022]
Abstract
Thoracic surgeons perform a wide variety of cancer operations, which are often associated with high morbidity and mortality. Thus, thoracic surgery involves many special challenges that require innovative solutions. The increased utilization of minimally invasive practices, poor overall cancer survival, and significant morbidity of critical operations remain key obstacles to overcome. Fluorescence imaging technology (FIT), involving the implementation of fluorescent dyes and imaging systems, is currently used as an adjunct for general thoracic surgery in many situations and includes sentinel lymph node mapping, pulmonary intersegmental plane identification, pulmonary nodule identification, pulmonary bullous lesion detection, evaluation of the anastomotic perfusion after tracheal surgery, and thoracic duct imaging for postoperative chylothorax. This technology enhances the surgeon's ability to perform operations, and has specific advantages. We review some of the key studies that demonstrate the applications of FIT in the field of general thoracic surgery, focusing on the use of indocyanine green.
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Affiliation(s)
- Yosuke Matsuura
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Junji Ichinose
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masayuki Nakao
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Sakae Okumura
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Mingyon Mun
- Department of Thoracic Surgical Oncology, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Slooter MD, Eshuis WJ, Cuesta MA, Gisbertz SS, van Berge Henegouwen MI. Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis. J Thorac Dis 2019; 11:S755-S765. [PMID: 31080655 DOI: 10.21037/jtd.2019.01.30] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Fluorescent imaging using indocyanine green (ICG) is an emerging technique that aids the surgeon with intraoperative decision making during upper gastrointestinal cancer surgery. In this systematic review we aim to provide an overview of current practice of fluorescence imaging using ICG during esophagectomy, and to show how this technology can prevent surgical morbidity, such as anastomotic leakage, graft necrosis and chylothorax. Methods The PRISMA standard for systematic reviews was used. The PubMed and Embase database were searched to identify articles matching our systematic literature search. Two authors screened all included articles for eligibility. Risk of bias was assessed for all included articles. Results A total of 25 articles were included in this review: 22 articles on perfusion assessment, and three on the detection of chyle fistula. Five out of 22 articles concerning perfusion assessment evaluated fluorescence signals in quantitative values. In 20 articles the pooled incidence of anastomotic leakage and graft necrosis in the ICG group was 11.10% (95% CI: 8.06-15.09%) and in eight studies the pooled change in management rate was 24.55% (95% CI: 19.16-30.88%). After change in management, the pooled incidence of anastomotic leakage and graft necrosis was 14.08% (95% CI: 6.55-27.70%). A meta-analysis showed that less anastomotic leakages and graft necrosis occur in the ICG group (OR 0.30, 95% CI: 0.14-0.63). Three case-reports (N=3) were identified regarding chyle fistula detection, and ICG lymphography detected the thoracic duct in all cases and the chyle fistula in one case. Conclusions Fluorescence imaging using ICG is a promising and safe technology to reduce surgical morbidity after esophagectomy with continuity restoration. ICG fluorescence angiography showed a reduction in anastomotic leakage and graft necrosis. Future studies are needed to demonstrate the feasibility of ICG lymphography for chyle fistula detection.
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Affiliation(s)
- Maxime D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Miguel A Cuesta
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Abstract
Intraoperative fluorescence imaging (FI) with indocyanine green has several potential uses during esophagectomy. Intravascular injection for enhancing the visualization of conduit vascularity and assessing macro and microperfusion has the most literature support and may help reduce anastomotic leaks. Peritumoral injection has been reported for use in identifying sentinel nodes during lymphadenectomy and intralymphatic injection may be used to help preserve or ligate the thoracic duct. The authors' own technique of FI for conduit assessment is described. They routinely use this strategy to guide anastomosis placement and reduce leaks.
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Affiliation(s)
- Simon R. Turner
- Division of Thoracic Surgery, University of Alberta, Edmonton, Canada 416 CSC, 10240 Kingsway Ave, Edmonton, AB, T5H 3V9,
| | - Daniela R. Molena
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY 1275 York Ave, New York, NY, 10065,
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14
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Chakedis J, Shirley LA, Terando AM, Skoracki R, Phay JE. Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol 2018; 25:3711-3717. [PMID: 30076554 DOI: 10.1245/s10434-018-6690-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Injury to the thoracic duct (TD) is the most common complication after a left lateral neck dissection, and it carries a high degree of morbidity. Currently, no routine diagnostic imaging is used to assist with TD identification intraoperatively. This report describes the first clinical experience with lymphangiography using indocyanine green (ICG) during lateral neck dissections. METHODS In six patients undergoing left lateral neck dissection (levels 2-4) for either thyroid cancer or melanoma, 2.5-5 mg of ICG was injected in the dorsum of the left foot 15 min before imaging. Intraoperative imaging was performed with a hand-held near infrared (NIR) camera (Hamamatsu, PDE-Neo, Hamamatsu City, Japan). RESULTS In five patients, the TD was visualized using NIR fluorescence, with a time of 15-90 min from injection to identification. Imaging was optimized by positioning the camera at the angle of the mandible and pointing into the space below the clavicle. No adverse reactions from the ICG injection occurred, and the time required for imaging was 5-10 min. No intraoperative TD injury was identified, and no chyle leak occurred postoperatively. For the one patient in whom the TD was not identified, it is unclear whether this was related to the timing of the injection or to duct obliteration from a prior dissection. CONCLUSION This is the first described application of ICG lymphangiography to identify the thoracic duct during left lateral neck dissection. Identification of TD with ICG is technically feasible, simple to perform with NIR imaging, and safe, making it a potential important adjunct for the surgeon.
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Affiliation(s)
- Jeffery Chakedis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Lawrence A Shirley
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Alicia M Terando
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Roman Skoracki
- Division of Oncologic Plastic Surgery, Department of Plastic Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - John E Phay
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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15
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Irie T, Matsutani T, Hagiwara N, Nomura T, Fujita I, Kanazawa Y, Kakinuma D, Uchida E. Successful treatment of non-occlusive mesenteric ischemia with indocyanine green fluorescence and open-abdomen management. Clin J Gastroenterol 2017; 10:514-518. [PMID: 28956274 DOI: 10.1007/s12328-017-0779-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/18/2017] [Indexed: 12/16/2022]
Abstract
Non-occlusive mesenteric ischemia (NOMI), which can lead to multifocal and segmental intestinal necrosis without demonstrable occlusion in the main mesenteric artery, is associated with extremely high mortality. Because these intestinal ischemic changes can progress, it is difficult to make a definitive determination intraoperatively as to whether resection of damaged intestine is required. A 62-year-old man who underwent esophagectomy for advanced cervicothoracic esophageal cancer complained of severe abdominal pain on postoperative day 4. Enhanced computed tomography revealed pneumatosis intestinalis in the wall of the small bowel. Emergency laparotomy revealed ischemia in segments of the small intestine suspicious for NOMI. Intraoperative evaluation of the mesenteric and bowel circulation was performed under indocyanine green (ICG) fluorescence. Although the ischemic bowel segments were visible, open-abdomen management was undertaken so that mesenteric and bowel circulation could be reexamined 24 h later. During the second-look operation, the small intestine was able to be preserved because intestinal perfusion was confirmed on revisualization under ICG fluorescence. The present case demonstrated that open-abdomen management and repeat visualization under ICG fluorescence are effective in preserving damaged intestine during surgery for NOMI.
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Affiliation(s)
- Toshiyuki Irie
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Takeshi Matsutani
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Nobutoshi Hagiwara
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Tsutomu Nomura
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Itsuo Fujita
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yoshikazu Kanazawa
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Daisuke Kakinuma
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Eiji Uchida
- Department of Gastrointestinal Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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16
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Lv S, Wang Q, Zhao W, Han L, Wang Q, Batchu N, Ulain Q, Zou J, Sun C, Du J, Song Q, Li Q. A review of the postoperative lymphatic leakage. Oncotarget 2017; 8:69062-69075. [PMID: 28978181 PMCID: PMC5620321 DOI: 10.18632/oncotarget.17297] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/11/2017] [Indexed: 12/14/2022] Open
Abstract
Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.
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Affiliation(s)
- Shulan Lv
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qing Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wanqiu Zhao
- Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Lu Han
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qi Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Nasra Batchu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qurat Ulain
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Junkai Zou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chao Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jiang Du
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qing Song
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA, USA.,Center of Big Data and Bioinformatics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qiling Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Center of Big Data and Bioinformatics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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17
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Landau MJ, Gould DJ, Patel KM. Advances in fluorescent-image guided surgery. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:392. [PMID: 27867944 DOI: 10.21037/atm.2016.10.70] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Fluorescence imaging is increasingly gaining intraoperative applications. Here, we highlight a few recent advances in the surgical use of fluorescent probes.
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Affiliation(s)
- Mark J Landau
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
| | - Daniel J Gould
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
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