Preventing chylothorax in minimally invasive esophagectomy: The role of intraoperative fluorescence imaging of the thoracic duct

To evaluate the efficacy of intraoperative indocyanine green (ICG) fluorescence imaging for the thoracic duct visualization in preventing chylothorax following minimally invasive esophagectomy (MIE). We retrospectively analyzed the clinical data of 648 patients who underwent MIE between January 2024 and January 2025. Based on intraoperative ICG fluorescence utilization, patients were stratified into two cohorts: ICG group (n = 101) and non-ICG group (n = 243). Propensity score matching (PSM) was performed to balance baseline covariates, resulting in 196 matched patients (98 per group). Primary outcomes included thoracic duct injury rate, chylothorax incidence, and perioperative outcomes. The thoracic duct was successfully visualized using ICG fluorescence in 98 % of cases. The ICG group demonstrated a significantly shorter operative time (p < 0.001) and a lower prophylactic thoracic duct ligation rate (8 % vs. 25 %, p = 0.002). Postoperative chylothorax occurred in 2 patients (2.0 %) in the ICG group and 9 (3.7 %) in the non-ICG group (p = 0.047). Multivariable analysis identified ICG fluorescence imaging (OR = 0.16, p = 0.033) and chronic obstructive pulmonary disease (OR = 5.54, p = 0.017) as independent predictors of chylothorax. ICG fluorescence imaging is a safe and effective technique that enhances intraoperative thoracic duct visualization, reduces postoperative chylothorax incidence, and shortens operative time in MIE.