Use of indocyanine green [ICG] for the identification of the thoracic duct in minimally invasive esophageal oncologic surgery

Chylothorax is a severe complication of esophagectomy, frequently caused by inadvertent injury due to the high anatomical variability of the thoracic duct. Fluorescence with Indocyanine Green (ICG) facilitates its identification, but standard subcutaneous injection protocols involve long latency periods that complicate surgical logistics. This study evaluates the efficacy of an optimized intranodal injection technique. We conducted a retrospective descriptive study of a consecutive cohort of 14 patients undergoing minimally invasive esophagectomy (MIE) for esophageal cancer following neoadjuvant therapy. Bilateral ultrasound-guided inguinal intranodal injection of ICG (4 mg in each inguinal region) was performed simultaneously with anesthesia induction, consuming no surgical time. The thoracic duct identification rate, latency time (injection-to-visualization), anatomical variants, and procedure safety were analyzed. The thoracic duct identification rate was 100%. The mean latency time was 31.3 ± 4.4 minutes, allowing for immediate visualization at the start of the thoracic phase without delays. Anatomical variants (aberrant patterns) were identified in 30% of cases. Fluorescence enabled the detection and repair of inadvertent intraoperative lymphatic leaks in 40% of patients. There were no complications associated with the procedure, and the incidence of postoperative chylothorax was 0%. Intranodal lymphography with ICG integrated into anesthesia induction is a safe and efficient technique. It eliminates operating room wait times associated with the subcutaneous route and allows for the detection of variants and occult leaks, effectively preventing postoperative chylothorax.