Intraoperative indocyanine green fluorescence lymphography, a novel imaging technique to detect a chyle fistula after an esophagectomy: Report of a case

Abstract

Intraoperative indocyanine green (ICG) lymphography was performed on a 62-year-old man, who was diagnosed to have chylothorax after an esophagectomy for esophageal cancer. After exploration of the thorax, a slowly increasing effusion was identified in the mediastinal space above the diaphragm, but the exact site of the lymph fistula could not be identified. By injecting 1.5 ml of ICG subcutaneously at the bilateral inguinal region, fluorescence images of the lymph flow in the thoracic cavity were obtained using a near-infrared camera system. The detected leakage point was sutured and the chyle ooze stopped. The postoperative course was uneventful. The patient was discharged on the 16th postoperative day. This is the first report using ICG fluorescence lymphography for the successful intraoperative detection of the exact site of a fistula causing chylothorax.

Emergency repair of a radiation-induced aortoesophageal fistula with endograft: Report of a case

“…21 Indocyanine green fl uorescence, a novel imaging technique, has been utilized to identify fi stulous chyle leaks, and is therefore considered to be a potentially useful diagnostic tool for aortoenteric fi stulas. 22 Endoscopy is the diagnostic tool of choice, with the most sensitivity and specifi city. 18,23 Endoscopic fi ndings depend on the timing of the examination.…”

Advances in fluorescent-image guided surgery

“…In a case of chylorrhea, intraoperative fluorescence navigation aided in thoracic duct ligation, successfully stopping the chylorrhea (92). These studies demonstrate that fluorescent probes could feasibly be employed to increase the efficiency of chylothorax and chylorrhea treatment and to reveal the pathogenesis of these poorly understood conditions (89,90,(92)(93)(94). As a whole, fluorescent visualization has the potential to significantly increase our understanding of the lymphatic system, guide surgical intervention, and manage therapies (95).…”

“…ICG fluorescence lymphography was also used intraoperatively in two adult patients with lymphatic injury following an esophagectomy (90,92). In one case of chylothorax, ICG fluorescent imaging was used to identify the precise site of a chyle fistula, allowing surgeons to suture it and prevent chyle leakage (90). In a case of chylorrhea, intraoperative fluorescence navigation aided in thoracic duct ligation, successfully stopping the chylorrhea (92).…”

“…In one case involving a pediatric patient with chylothorax, ICG fluorescence helped physicians visualize obstructed lymphatic drainage and guide the choice of surgical intervention (89). ICG fluorescence lymphography was also used intraoperatively in two adult patients with lymphatic injury following an esophagectomy (90,92). In one case of chylothorax, ICG fluorescent imaging was used to identify the precise site of a chyle fistula, allowing surgeons to suture it and prevent chyle leakage (90).…”

“…Fluorescent imaging of lymphatic flow has been used outside of the realm of cancer and lymphedema as a means of aiding therapy for chylothorax (89,90). Chylothorax results from leakage of lymph from the thoracic duct or its tributaries, causing chyle to accumulate within the pleural cavity (89,91).…”