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Evans MJ, Bunola-Hadfield EE, Sowkoor JS, Malik TY, Master H, Sultana E, Mohamed AO, Alqaseer AM, Ismail AT, Mafi P, Rahman S. The efficacy of indocyanine green fluorescence in facilitating thoracic duct visualisation and mitigating injury in cervicothoracic surgery: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 2025; 63:349-356. [PMID: 40374490 DOI: 10.1016/j.bjoms.2025.03.013] [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: 11/28/2024] [Revised: 03/08/2025] [Accepted: 03/16/2025] [Indexed: 05/17/2025]
Abstract
Chyle leak following injury to the thoracic duct (TD) is an uncommon but serious complication of cervicothoracic procedures, including neck dissection and oesophagectomy, and has significant morbidity and mortality. We aimed to investigate the efficacy of indocyanine green (ICG) fluorescence in facilitating intraoperative TD visualisation and preventing chyle leaks. A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards for studies that assessed ICG for TD visualisation in cervicothoracic procedures. The primary outcome measure was TD visualisation using ICG. Secondary outcomes included rates of chyle leak detection, visualisation rate in white light, and time from injection to visualisation. Twelve studies enrolling 475 subjects met the inclusion criteria. The TD visualisation rate with ICG was 93.3% (SE 0.013, p < 0.001) compared with 54.3% (SE 0.065, p < 0.001) in white light. Detection rates for intraoperative chyle leak were higher using ICG compared with no ICG use: 74% (SE 0.047, p < 0.001) vs 17.5% (SE 0.086, p = 0.043), respectively. ICG reduced rates of postoperative chyle leak from 10.1% (untransformed proportion metric: 0.101 (0.045, 0.157), p < 0.001) to 3.9% (SE 0.021, p = 0.061). Mean time from ICG injection to TD visualisation was 83.94 minutes (p < 0.001). ICG offers an effective method of TD visualisation in cervicothoracic surgery. It can reduce rates of chyle leak and mitigate adverse sequelae from inadvertent duct injury. High-quality randomised controlled trials are required to improve the evidence base.
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Affiliation(s)
- Martin J Evans
- Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, United Kingdom.
| | | | | | | | - Hussain Master
- Senior House Officer in Respiratory Medicine, Royal Preston Hospital, United Kingdom.
| | | | | | | | | | - Pouya Mafi
- Queen Elizabeth Hospital, Birmingham, United Kingdom.
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Luo X, Lu D, Wang Z, Wang J, Dong R, Wang Y, Cao W, Jin D, Lin Z, Li H, Du P, Gou Y, Dong P, Yang Y. Impact of enhanced chest CT with three-dimensional reconstruction combined with preoperative olive oil administration on the incidence of postoperative chylothorax: a retrospective study. J Cardiothorac Surg 2025; 20:112. [PMID: 39893382 PMCID: PMC11786395 DOI: 10.1186/s13019-024-03319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Accepted: 12/26/2024] [Indexed: 02/04/2025] Open
Abstract
BACKGROUND Chylothorax is a rare but potentially life-threatening complication after esophageal cancer resection. This study aims to investigate the impact of a strategy combining preoperative three-dimensional (3D) reconstruction of contrast-enhanced chest CT with olive oil ingestion on the incidence of chylothorax following esophageal cancer resection. METHODS We retrospectively analyzed the clinical data of 357 patients who underwent esophageal cancer resection in the Department of Thoracic Surgery at Gansu Provincial People's Hospital from January 2019 to June 2024. Among them, 179 patients who underwent preoperative 3D reconstruction of contrast-enhanced chest CT combined with oral olive oil administration were assigned to the 3D reconstruction group, while 158 patients who did not receive these interventions served as the control group. The primary outcome measures included the incidence of chylous leakage and related perioperative outcomes. RESULTS All patients in both groups underwent surgeries successfully without any perioperative deaths. Compared to the control group, the 3D reconstruction group exhibited a significant decrease in the incidence of postoperative chylothorax (0% versus 8.2%, P < 0.001). The visualization rate of the thoracic duct during surgery was higher in the 3D reconstruction group compared to the control group (93.85% vs. 48.73%). Furthermore, patients in the 3D reconstruction group had less intraoperative bleeding (P = 0.003), shorter postoperative hospital stays (P = 0.003), and reduced chest drainage in the first three postoperative days (P < 0.001). CONCLUSION This study reveals that preoperative three-dimensional reconstruction of chest using enhanced CT allows for the anticipation of thoracic duct anatomy. Additionally, the combination of preoperative oral olive oil administration significantly enhances the intraoperative visualization of the thoracic duct. This integrated strategy effectively reduces the incidence of postoperative chylothorax, demonstrating promising clinical application prospects.
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Affiliation(s)
- Xindong Luo
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
- Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agricultural and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of Chinese Academy of Agricultural Sciences, Lanzhou, China
| | - Di Lu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agricultural and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of Chinese Academy of Agricultural Sciences, Lanzhou, China
| | - Ziqiang Wang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jingyi Wang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Ruozhu Dong
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Yaping Wang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Wei Cao
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Zhaohao Lin
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Haochi Li
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Pengcheng Du
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
- Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agricultural and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of Chinese Academy of Agricultural Sciences, Lanzhou, China.
| | - Pengcheng Dong
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China.
- Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agricultural and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of Chinese Academy of Agricultural Sciences, Lanzhou, China.
| | - Yayuan Yang
- Key Laboratory of Veterinary Pharmaceutical Development, Ministry of Agricultural and Rural Affairs, Lanzhou Institute of Husbandry and Pharmaceutical Sciences of Chinese Academy of Agricultural Sciences, Lanzhou, China.
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Tsuchitani Y, Ozawa Y, Taniyama Y, Okamoto H, Sato C, Ishida H, Kamei T. Risk Factors and Treatment of Chylothorax After Minimally Invasive Esophagectomy for Esophageal Cancer. Cureus 2024; 16:e65606. [PMID: 39205723 PMCID: PMC11350151 DOI: 10.7759/cureus.65606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2024] [Indexed: 09/04/2024] Open
Abstract
Background Postoperative chylothorax is a rare but life-threatening complication of esophagectomy. However, due to its rarity, researching the risk factors and selecting appropriate treatment options has been limited. Methods This study included 727 patients with esophageal cancer who underwent minimally invasive esophagectomy at our hospital. To detect the risk factors for chylothorax, we divided the patients into two groups, with and without postoperative chylothorax. We then compared patient characteristics, tumor-specific variables, and operative details. Subsequently, we analyzed the peri-treatment characteristics and outcomes for the three distinct treatment options we had chosen: surgery, conversion (the group that finally underwent surgery after unsuccessful conservative treatment), and conservative. Results Of the 727 patients, 18 (2.5%) developed a chylothorax. The mean BMI was lower (20.3 vs. 21.9, p=0.057), and more cases of thoracic duct resection were found in the chylothorax group (33.3% vs. 6.2%, p=0.001), with statistical significance. Multivariate analysis identified thoracic duct resection as a risk factor (adjusted odds ratio, 6.83). The drainage volume two days after chylothorax was higher in the surgery group, although the difference was not statistically significant (surgery group, 1,405 ml vs. conversion group, 260 ml vs. conservative group, 310 ml; p=0.073). The surgery group had the shortest median postoperative hospital days among these groups (21.5 as compared to 102 and 25.0 days in the conversion and conservative groups, respectively; p<0.001). None of the patients died during their hospital stays. Conclusion Thoracic duct resection during the initial minimally invasive esophagectomy was an independent risk factor for chylothorax. If drainage volume does not decrease on the second day, early surgery may lead to earlier discharge.
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Affiliation(s)
- Yuma Tsuchitani
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
| | - Yohei Ozawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Hospital, Sendai, JPN
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
| | - Hirotaka Ishida
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, JPN
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Berger Y, Bard V, Abbas M, Solomon D, Menasherov N, Kashtan H. Thoracic Duct Visualization in Esophageal Resection: A Pilot Trial. Eur Surg Res 2024; 65:60-68. [PMID: 38636484 DOI: 10.1159/000538691] [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: 12/26/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Inadvertent thoracic duct injury is common during esophagectomy and may result in postoperative chylothorax. This study's objective was to investigate utility of patent blue injection as a modality for intraoperative thoracic duct visualization. METHODS A prospective, single-arm, interventional study of patients undergoing minimally invasive esophagectomy was performed. Patients were injected with patent blue dye into both groins prior to thoracic stage of surgery and assessed for duct visualization. Control group was formed by propensity score matching using retrospectively collected data regarding patients who underwent esophagectomy. RESULTS A total of 25 patients were included in analysis, compared to a control of 50 patients after matching. Thoracic duct was visualized in 60% of patients in the study group (15/25 patients). Significant differences were found between study and control groups (p < 0.05) with regards to median operative time (422 vs. 285 min, respectively), overall complications (16 vs. 34%, respectively), and median postoperative length of stay (13.5 vs. 10 days, respectively). There was a difference in rate of chyle leak between study and control groups; however, this was not significant (0 vs. 12%, respectively, p = 0.17). CONCLUSION Patent blue injection represents a simple method for thoracic duct visualization during minimally invasive esophagectomy which may improve surgical outcomes.
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Affiliation(s)
- Yael Berger
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vyacheslav Bard
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Muhammad Abbas
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Solomon
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nikolai Menasherov
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanoch Kashtan
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Higuchi T, Ozawa S, Koyanagi K, Oguma J, Ninomiya Y, Yatabe K, Yamamoto M, Nomura T, Niwa T. Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer. Esophagus 2021; 18:753-763. [PMID: 33770289 DOI: 10.1007/s10388-021-00832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/20/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.
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Affiliation(s)
- Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Takakiyo Nomura
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsu Niwa
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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Kutara K, Kanda T, Maeta N, Mochizuki Y, Ono F, Itoh Y, Asanuma T. Combining non-contrast enhanced magnetic resonance thoracic ductography with vascular contrast-enhanced computed tomography to identify the canine thoracic duct. Open Vet J 2020; 10:68-73. [PMID: 32426259 PMCID: PMC7193886 DOI: 10.4314/ovj.v10i1.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/12/2020] [Indexed: 11/26/2022] Open
Abstract
Background: In humans, visualization of the thoracic duct by magnetic resonance imaging (MRI) has been attempted, and recent advances have enabled clinicians to visualize the thoracic duct configuration in a less invasive manner. Moreover, MRI does not require contrast media, and it enables visualization of morphological details of the thoracic structures. In veterinary practice, the thoracic duct has not been visualized three dimensionally in MRI. Aim: This study aimed to assess the performance of our magnetic resonance thoracic ductography (MRTD) technique to visualize the thoracic duct and the surrounding 3D anatomical structures by combining MRTD and vascular contrast-enhanced thoracic computed tomography (CT) images in dogs. Methods: Five adult male beagle dogs (11.4–12.8 kg) were included in this study. Sagittal and transverse T2-weighted images were scanned in MRI. Scanning in MRTD used a single-shot fast spin echo sequence with a respiratory gate. CT was performed after the intravenous injection of contrast medium. All MRTD and CT images were merged using a workstation. Results: The thoracic ducts were identified in MRTD images of all dogs, and the surrounding anatomical structures were located with the aid of contrast-enhanced thoracic CT. In all dogs, the thoracic ducts coursed along the right-dorsal side of the aorta, cranially from the L2 level. Thereafter, these bent to the left side at the aortic arch and curved at the left external jugular vein angle. A comparison of the number of thoracic ducts at each vertebra between transverse T2WI and MRTD did not reveal any significant differences for all vertebrae. Conclusion: The results from our study suggest that MRTD using the single-shot fast spin echo sequence could be a useful tool for visualization of the thoracic duct. Furthermore, the image merged from MRTD and vascular-enhanced images provided detailed anatomical annotation of the thorax. The MRTD protocol described in this study is safe and easily adaptable, without the need for contrast medium injection into the lymph system. In addition, the images fused from MRTD and vascular contrast-enhanced CT image of the thorax could provide detailed anatomical annotations for preoperative planning.
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Affiliation(s)
- Kenji Kutara
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Teppei Kanda
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Noritaka Maeta
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Yohei Mochizuki
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Fumiko Ono
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Yoshiki Itoh
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
| | - Taketoshi Asanuma
- Faculty of Veterinary Medicine, Okayama University of Science, Imabari, Japan
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