EFFECTIVENESS OF INDOCYANINE GREEN FLUORESCENCE FOR THE IDENTIFICATION OF THORACIC DUCT IN RECURRENT IDIOPATHIC CHYLOTHORAX

In this Video we present the intraoperative use of indocyanine green lymphography in a patient with recurrent idiopathic chylothorax refractory to conservative therapy. In those patients, a thick mediastinal pleura, caused by prior surgery and/or inflammatory adhesions, could make the identification of the thoracic duct challenging. The indocyanine green (often called ICG) quickly allows to discriminate between thoracic duct and adhesions, which do not present infrared signal. Following the fluorescence signal, the thoracic duct is finally identified and prepared along its course. Indocyanine green is injected 30’ before surgery in the inguinal lymph nodes bilaterally combined with albumin. TD is clearly identified between the adhesions using the D-LIGHT mode of the camera while its identification with normal light view is difficult. In addition, we also administered a fatty meal before surgery. However, no chylous leakage was evident with normal light view in this case. Only the ICG fluorescence allows to identify the leaking spot in the context of pleural adhesions just above the diaphragm. The injection of ICG was performed under general anesthesia after intubation by a dedicated radiologist. In order to optimize the lymphatic drainage, ¾ of the ICG were injected in the peri-nodal region and ¼ into the core of the lymph node. This thecnique provides a clear and long-lasting signal of the TD course both under D-light mode and SPECTRA A mode. The lesion is finally well identified and the thoracic duct is repaired so that the leaking stops. The recovery was uneventful and the patient was discharged on postoperative day 5. At 1-year follow up there is no sign of recurrence.