Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy

Thomas G Barnes, Thomas MacGregor, Bruno Sgromo, Nicholas D Maynard, Richard S Gillies, Thomas G Barnes, Thomas MacGregor, Bruno Sgromo, Nicholas D Maynard, Richard S Gillies

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).

Keywords: Fluorescence; Indocyanine green; Minimally invasive surgery; Oesophagectomy; Thoracic duct leaks.

Conflict of interest statement

Authors Thomas G. Barnes, Thomas MacGregor, Bruno Sgromo, Nicholas D. Maynard, and Richard S. Gillies have no conflicts of interest or financial ties to disclose.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Study flow diagram
Fig. 2
Fig. 2
Representative image of fluorescent small bowel following ICG-cream mix infiltrated via a feeding jejunostomy
Fig. 3
Fig. 3
Signal to background ratio over time. Red triangles = individual measurements, solid blue line = mean, dashed blue line = 95% confidence interval (Color figure online)
Figs. 4
Figs. 4
Representative images of white light and near infra-red fluorescence of the thoracic duct during minimally invasive thoracic dissection of the oesophagus. Note that in both images, the thoracic duct cannot be clearly seen under white light but can clearly be seen with fluorescence (green) (Color figure online)
Fig. 5
Fig. 5
Representative images of identifying chyle leak under fluorescence in two patients. A and B represent two separate participants. Ai—image under fluorescence identifying fluorescent ‘pool’ of fluid (white line). Aii—image with white light outlining area of thoracic duct. Aiii clipped thoracic duct under fluorescence. Bi = fluorescent image outlining (white line) thoracic duct and adjacent to this fluorescent fluid. Bii—white light image of Bi. Biii—white light image following clipping of thoracic duct

References

    1. Rao DV, Chava SP, Sahni P, et al. Thoracic duct injury during esophagectomy: 20 years experience at a tertiary care center in a developing country. Dis Esophagus. 2004;17:141–145. doi: 10.1111/j.1442-2050.2004.00391.x.
    1. Kranzfelder M, Gertler R, Hapfelmeier A, et al. Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis. Surg Endosc. 2013;27:3530–3538. doi: 10.1007/s00464-013-2991-7.
    1. Brinkmann S, Schroeder W, Junggeburth K, et al. Incidence and management of chylothorax after ivor lewis esophagectomy for cancer of the esophagus. J Thorac Cardiovasc Surg. 2016;151:1398–1404. doi: 10.1016/j.jtcvs.2016.01.030.
    1. Shackcloth MJ, Poullis M, Lu J, et al. Preventing of chylothorax after oesophagectomy by routine pre-operative administration of oral cream. Eur J Cardiothorac Surg. 2001;20:1035–1036. doi: 10.1016/S1010-7940(01)00928-9.
    1. McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med. 2010;104:1–8. doi: 10.1016/j.rmed.2009.08.010.
    1. Ashitate Y, Tanaka E, Stockdale A, et al. Near-infrared fluorescence imaging of thoracic duct anatomy and function in open surgery and video-assisted thoracic surgery. J Thorac Cardiovasc Surg. 2011;142(31–38):e31–32. doi: 10.1016/j.jtcvs.2011.03.004.
    1. Kamiya K, Unno N, Konno H. Intraoperative indocyanine green fluorescence lymphography, a novel imaging technique to detect a chyle fistula after an esophagectomy: report of a case. Surg Today. 2009;39:421–424. doi: 10.1007/s00595-008-3852-1.
    1. Kaburagi T, Takeuchi H, Oyama T, et al. Intraoperative fluorescence lymphography using indocyanine green in a patient with chylothorax after esophagectomy: report of a case. Surg Today. 2013;43:206–210. doi: 10.1007/s00595-012-0391-6.
    1. Chang TI, Chen YS, Huang SC. Intraoperative indocyanine green fluorescence lymphography to detect chylous leakage sites after congenital heart surgery. J Thorac Cardiovasc Surg. 2014;148:739–740. doi: 10.1016/j.jtcvs.2014.03.021.
    1. Matsutani T, Hirakata A, Nomura T, et al. Transabdominal approach for chylorrhea after esophagectomy by using fluorescence navigation with indocyanine green. Case Rep Surg. 2014;2014:464017.
    1. Vecchiato M, Martino A, Sponza M, et al. Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position. Dis Esophagus. 2020 doi: 10.1093/dote/doaa030.
    1. McCulloch P, Altman DG, Campbell WB, et al. No surgical innovation without evaluation: the ideal recommendations. Lancet. 2009;374:1105–1112. doi: 10.1016/S0140-6736(09)61116-8.
    1. Hagens ERC, van Berge Henegouwen MI, Cuesta MA, et al. The extent of lymphadenectomy in esophageal resection for cancer should be standardized. J Thorac Dis. 2017;9:S713–S723. doi: 10.21037/jtd.2017.07.42.
    1. Schurink B, Defize IL, Mazza E, et al. Two-field lymphadenectomy during esophagectomy: the presence of thoracic duct lymph nodes. Ann Thorac Surg. 2018;106:435–439. doi: 10.1016/j.athoracsur.2018.02.047.
    1. Udagawa H, Ueno M, Shinohara H, et al. Should lymph nodes along the thoracic duct be dissected routinely in radical esophagectomy? Esophagus. 2014;11:204–210. doi: 10.1007/s10388-014-0433-9.
    1. Matsuda S, Takeuchi H, Kawakubo H, et al. Clinical outcome of transthoracic esophagectomy with thoracic duct resection: number of dissected lymph node and distribution of lymph node metastasis around the thoracic duct. Medicine (Baltimore) 2016;95:e3839. doi: 10.1097/MD.0000000000003839.
    1. Steffey MA, Mayhew PD. Use of direct near-infrared fluorescent lymphography for thoracoscopic thoracic duct identification in 15 dogs with chylothorax. Vet Surg. 2018;47:267–276. doi: 10.1111/vsu.12740.
    1. Yang F, Zhou J, Li H, et al. Near-infrared fluorescence-guided thoracoscopic surgical intervention for postoperative chylothorax. Interact Cardiovasc Thorac Surg. 2018;26:171–175. doi: 10.1093/icvts/ivx304.

Source: PubMed

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