Video-assisted thoracoscopic thoracic duct ligation with near-infrared fluorescence imaging with indocyanine green

A comparative study of indocyanine green instillation in inguinal node versus foot web space using da Vinci indocyanine green FireFly™ technology in identifying thoracic duct during robotic-assisted transthoracic oesophagectomy

INTRODUCTION

Chyle leak is a serious complication following oesophagectomy with incidence varies from 1% to 9%. Near infra-red fluorescence imaging of thoracic duct (TD) can provide real-time dynamic imaging during the surgery. In this study, we intend to compare indocyanine green (ICG) dye instillation through inguinal node with subcutaneous first web space instillation for visualisation of TD during robotic-assisted minimally invasive oesophagectomy (RAMIE) procedure.

PATIENTS AND METHODS

A prospective study of 50 patients underwent RAMIE with da Vinci X System. After general anaesthesia, patients were divided into inguinal node and foot first web space ICG instillation group. The former group had 1 ml of ICG dye instilled on bilateral inguinal nodes under ultrasound guidance and while the other group received 1 mL of ICG dye injected at bilateral foot first web space and then underwent surgery. TD was visualised using ICG FireFly™ fluorescence technology, first at the time of docking and subsequently for every 5 min until 60 min of instillation time and analysed.

RESULTS

Twenty-five patients were enrolled in each group. The mean docking time for thoracic phase was 13.76 ± 3.43 min. TD was visualised in 72% (18/25) of cases of first web space instillation group, whereas 100% in ultrasound guidance inguinal node instillation group. None of the patients had a chyle leak.

CONCLUSION

ICG FireFly™ fluorescence technology for the identification of TD during oesophageal mobilisation is safe and effective and provides real-time dynamic visualisation with high accuracy in ultrasound-guided bilateral inguinal node instillation group. It is an effective method for the surgeons planning to negotiate their initial learning curve in RAMIE procedures.

Expert consensus on indocyanine green fluorescence imaging for thoracoscopic lung resection (The Version 2022)

The use of the white-light thoracoscopy is hampered by the low contrast between oncologic margins and surrounding normal parenchyma. As a result, many patients with in situ or micro-infiltrating adenocarcinoma have to undergo lobectomy due to a lack of tactile and visual feedback in the resection of solitary pulmonary nodules. Near-infrared (NIR) guided indocyanine green (ICG) fluorescence imaging technique has been widely investigated due to its unique capability in addressing the current challenges; however, there is no special consensus on the evidence and recommendations for its preoperative and intraoperative applications. This manuscript will describe the development process of a consensus on ICG fluorescence-guided thoracoscopic resection of pulmonary lesions and make recommendations that can be applied in a greater number of centers. Specifically, an expert panel of thoracic surgeons and radiographers was formed. Based on the quality of evidence and strength of recommendations, the consensus was developed in conjunction with the Chinese Guidelines on Video-assisted Thoracoscopy, and the National Comprehensive Cancer Network (NCCN) guidelines on the management of pulmonary lesions. Each of the statements was discussed and agreed upon with a unanimous consensus amongst the panel. A total of 6 consensus statements were developed. Fluorescence-guided thoracoscopy has unique advantages in the visualization of pulmonary nodules, and recognition and resection of the anterior plane of the pulmonary segment. The expert panel agrees that fluorescence-guided thoracoscopic surgery has the potential to become a routine operation for the treatment of pulmonary lesions.

Fluorescence-guided cancer surgery-A new paradigm

Fluorescence-guided surgery is an emerging and promising operative adjunct to assist the surgeon in various aspects of oncosurgery, ranging from assessing perfusion, identification, and characterization of tumors and peritoneal metastases, mapping of lymph nodes/leaks, and assistance for fluorescence-guided surgery (FGS). This study aims to provide an overview of principles, currently available dyes, platforms, and surgical applications and summarizes the available literature on the utility of FGS with a focus on abdomino-thoracic malignancies.

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.