J. M. Chakedis1, L. A. Shirley1, A. M. Terando1, R. Skoracki2, J. Phay1 1The Ohio State University Wexner Medical Center And James Cancer Hospital And Solove Research Institute,Division Of Surgical Oncology, Department Of Surgery,Columbus, OH, USA 2The Ohio State University Wexner Medical Center And James Cancer Hospital And Solove Research Institute,Division Of Oncologic Plastic Surgery, Department Of Plastic Surgery,Columbus, OH, USA
Introduction:
Injury to the thoracic duct causing a chyle leak is a common complication following a left modified radical neck dissection, and carries a high degree of morbidity when it occurs. There are no interventions or diagnostics which are routinely used to assist with thoracic duct identification intra-operatively. Lymphangiography using Indocyanine Green (ICG) has previously been described for sentinel lymph node biopsy and for the evaluation and management of lymphedema. To our knowledge, there have been no reports of the use of ICG lymphangiography for mapping the thoracic duct during neck dissection. Here we present the first clinical experience with this technique.
Methods:
In 5 patients undergoing left modified radical neck dissection for either thyroid cancer or melanoma, Indocyanine Green (2.5 mg/mL) 1mL was injected subcutaneously on the dorsum of the left foot 15-50 minutes before imaging. The neck dissection was performed until either the thoracic duct was identified or the suspected area was dissected clean. At this point, intraoperative imaging of the neck was performed with a hand-held Near InfraRed (NIR) camera (Hamamatsu PDE-Neo).
Results:
In 4 out of 5 patients the thoracic duct was visualized using the NIR camera. The thoracic duct was identified with dissection alone in 1 out of 4 patients, and the area around the normal anatomical location was cleared in the other 3. Time from injection to identification of the thoracic duct was variable at 15 to 90 minutes. Imaging was optimized by positioning the camera at the angle of the mandible and pointing down the neck into the space below the clavicle in a caudal direction (Figure 1). There were no adverse reactions from ICG injection; and the total time required to perform imaging was 5-15 minutes. No leakage from the thoracic duct was identified in any patient, and all patients’ postoperative courses were uncomplicated. In the 1 patient in whom the duct was not identified, it is unclear if non-visualization was related to the timing of the injection, duct obliteration due to a prior dissection in this area, or another factor.
Conclusion:
This is the first description of using ICG lymphangiography for identification of the thoracic duct during left modified radical neck dissection. Identification with ICG is technically feasible, simple to perform with NIR imaging, and safe. This technique can be a helpful adjunct to the surgeon to facilitate identification of the thoracic duct and thereby reduce post-operative complications.
