SYSTEMATIC REVIEW article
Front. Oncol.
Sec. Surgical Oncology
This article is part of the Research TopicAdvances in Esophageal Cancer: Treatment Updates and Future ChallengesView all 37 articles
Indocyanine Green-assisted Lymphography for Intraoperative Chyle Leak Prevention during Esophageal Cancer Surgery: a Systematic Review of the Literature
Provisionally accepted
Francesco Puccetti1,2
Francesco Saverio Candiloro1
Lorenzo Cinelli2*
Silvia Battaglia2Lorenzo Gozzini2
Ugo Elmore1,2
Riccardo Rosati1,2- 1Vita-Salute San Raffaele University, Milan, Italy
- 2IRCCS Ospedale San Raffaele, Milan, Italy
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Background and aim Chyle leakage (CL) is a potentially life-threatening complication, severely impacting postoperative recovery after esophageal cancer resections. Indocyanine green-assisted lymphography (ICG-Lg) seems to provide a fluorescent visualization of the thoracic duct (TD), although the optimal approach for CL prevention has not been defined. Methods This study was designed as a systematic review and included either randomized or observational reports regarding ICG-Lg during esophageal cancer resections. The literature search was conducted on PubMed, Embase, and Scopus databases, and original articles combining ICG-Lg during esophageal cancer resections were selected. The rate of TD visualization was primarily investigated, while secondary outcomes included procedural complications, CL incidence, length of stay, and lymph node harvest (LNH). The review was registered on PROSPERO (CRD42025638309) and was performed according to PRISMA guidelines. Results Thirteen non-randomized articles were selected, including 1218 patients undergoing surgery for esophageal cancer. MINORS study quality assessment showed moderate scores (74.5%). The TD was correctly visualized in 95.4% and generally preserved (68.1%) for CL prevention. Procedural complications were negligible (0.1%), and CL occurrence was significantly lower after ICG-Lg (1.4 vs 5.4%, P<0.001). The studies demonstrated a shorter LOS (OR -0.13, 95% CI -0.30 to 0.04, P=0.273) and a significantly higher LNH (OR 0.40, 95% CI -0.20 to 1.00, P<0.001) after ICG-Lg. Conclusions Although intraoperative ICG-Lg provides a safe and effective TD visualization during esophagectomy, minimization of postoperative CL and maintenance of extensive lymph node dissection depends on the surgical strategy. Randomized trials should be specifically designed to identify surgical determinants of CL prevention in esophageal cancer surgery.
Keywords: Chyle leakage, esophageal cancer, Esophagectomy, fluorescence-guided surgery, minimally invasive surgery
Received: 07 Nov 2025; Accepted: 16 Feb 2026.
Copyright: © 2026 Puccetti, Candiloro, Cinelli, Battaglia, Gozzini, Elmore and Rosati. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Lorenzo Cinelli
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