Technical Performance and Clinical Utility of Indocyanine Green Thoracic Duct Lymphography During Esophagectomy: A Systematic Review and Meta-analysis
In brief
ICG visualizes thoracic duct in 95% of esophagectomies, no leak reduction
Near-infrared ICG fluorescence identified the thoracic duct in about 95% of patients undergoing esophagectomy and was reported safe, but comparative data showed it did not lower the rate of postoperative chyle leak or need for re-intervention. Larger, well-designed trials are needed to prove any clinical benefit beyond anatomy guidance.
- Journal
- Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract (Q1)
- Published
- 7 September 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Syed Nusrath, Devendra Ghanshyam Parikh, Rodolfo J Oviedo, Luigi Marano, Ajit Agarwal, Ashwin K R
- PMID
- 42705599
- DOI
- 10.1016/j.gassur.2026.102581
Why clinicians should know about it
- Picked for Anatomy (paper of the day, 9 September 2026): ICG fluorescence lymphography provides reliable intraoperative visualization of thoracic duct
Abstract
BACKGROUND: Postoperative chylothorax is an uncommon but serious complication of esophagectomy, usually caused by thoracic duct injury. Indocyanine green (ICG) near-infrared fluorescence lymphography has been used to improve intraoperative identification of the thoracic duct. This systematic review and meta-analysis evaluated its technical performance, safety, and effect on postoperative chyle leak. METHODS: Clinical studies of ICG-guided thoracic duct visualization during primary esophagectomy were included. The primary outcome was successful visualization of thoracic duct. Secondary outcomes included route-specific success, postoperative chyle leak, changes in operative management, and adverse events. Random-effects meta-analysis of proportions and risk ratios was performed. Risk of bias was assessed with ROBINS-I and the Joanna Briggs Institute checklist. RESULTS: Sixteen studies were included. Thoracic duct visualization, a primary technical endpoint, was achieved in 656/702 patients (pooled rate 94.8%, 95% CI 87.6-97.9%; I² = 66.6%). Visualization was higher with intranodal than subcutaneous administration (98.2% vs 92.9%; subgroup p = 0.029). Across 16 cohorts, chyle leak occurred in 22/853 patients (2.58%). In five comparative studies, ICG did not significantly reduce chyle leak (RR 0.61, 95% CI 0.21-1.80; p = 0.277) or reintervention (RR 0.97, 95% CI 0.36-2.65; p = 0.94). No clinically significant adverse events occurred in 653 patients; comparative studies had serious risk of bias. CONCLUSIONS: ICG fluorescence lymphography provides highly reliable intraoperative visualization of the thoracic duct and appears safe. However, visualization represents a technical rather than patient-important clinical endpoint, and the available evidence does not demonstrate a reduction in postoperative chyle leak or reintervention. ICG should therefore be regarded as an anatomical-navigation tool whose clinical effectiveness remains to be established in adequately powered prospective comparative studies.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.