近红外成像引导和预防性结扎胸导管，有效降低微创食管切除术后的乳糜漏发生率

The Near-Infrared Visualization and Preemptive Ligation of the Thoracic Duct Effectively Reduce the Chyle Leak Incidence After Minimally Invasive Esophagectomy

ANNALS OF SURGERY

影响因子:6.4

分区:医学1区 Top / 外科1区

发表日期:2024 Nov 01

作者: Francesco Puccetti, Lorenzo Cinelli, Lavinia A Barbieri, Davide Socci, Di Serio Clelia, Francesco De Cobelli, Ugo Elmore, Riccardo Rosati,

DOI: 10.1097/SLA.0000000000006490

摘要

本研究旨在评估吲哚菁绿（ICG）引导淋巴造影（ICG-Lg）在减少食管切除术后乳糜漏（CL）发生率方面的有效性。乳糜胸可能严重影响食管癌手术的效果，而预防性结扎胸导管（TD）是目前最常用的控制手段。近年来，ICG-Lg已被引入微创食管切除中，便于TD的检测和预防性结扎。本回顾性分析包括2018年1月至2023年8月期间在三级转诊中心接受微创Ivor Lewis食管切除的连续患者，所有患者均接受扩展淋巴结清扫并结扎、切除胸导管。所有2021年1月后接受治疗的患者均行ICG-Lg以识别和结扎TD（ICG组），并与之前的无ICG组进行比较。主要观察指标为术后乳糜漏的发生率，通过单变量和向后逐步多变量逻辑回归模型识别相关因素。共包括320名患者，151名（ICG组）接受ICG-Lg。两组患者除新辅助治疗（P<0.001）和术前合并症（P=0.045）外，其他特征均相似。ICG-Lg显著降低了术后乳糜漏的发生率（11.8%对4.6%，P=0.026），并显著缩短住院中位天数（13天对9天，P=0.006）。然而，ICG组的乳糜漏患者更可能需要再次手术修复（P=0.050）。结论：术中ICG-Lg显著降低了微创全食管切除术后的乳糜漏发生率，因此应在高容量中心的标准手术流程中常规应用，以提高手术安全性。

Abstract

The aim of the present study is to assess the effectiveness of indocyanine-green (ICG)-guided lymphography (ICG-Lg) in reducing the incidence of chyle leak (CL) after esophagectomy.Chylothorax may severely impact esophageal cancer surgery, and the pre-emptive ligation of the thoracic duct (TD) is the most widespread control of this complication. Intraoperative ICG-Lg has been recently embedded in minimally invasive esophagectomy to facilitate TD detection and pre-emptive ligation.This retrospective analysis included consecutive patients who underwent minimally invasive Ivor Lewis esophagectomy for cancer at a tertiary referral center between January 2018 and August 2023. Patients were routinely submitted to extended lymphadenectomy with TD ligation and removal. All patients treated after January 2021 underwent ICG-Lg for TD identification and ligation (ICG group) and compared with the previous series (no-ICG group). The primary outcome was the incidence of postoperative CL, while univariate and backward stepwise multivariate logistic regression models were performed to identify associated factors.After including 320 patients, 151 (ICG group) were submitted to ICG-Lg before the pre-emptive TD ligation. Both groups presented similar characteristics, except for neoadjuvant therapy ( P <0.001) and preoperative comorbidities ( P =0.045). Intraoperative ICG-Lg significantly reduced the incidence of postoperative CL (11.8% vs 4.6%, P =0.026) and was significantly associated with shorter median length of hospital stay (13 vs 9 d, P =0.006). However, CL after ICG-Lg was more likely to require repairing reoperation ( P =0.050).Intraoperative ICG-Lg demonstrated significantly lower rates of CL after total minimally invasive esophagectomy and, therefore, it should be routinely embedded in the standardized surgical technique of high-volume centers for esophageal cancer.