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Case Reports
. 2025 Jan-Dec;18(1):e70067.
doi: 10.1111/ases.70067.

Real-Time Identification of Lymph Vessels Using Indocyanine Green in a Patient With Chylothorax Associated With Lymphangioleiomyomatosis

Shinichi Sakamoto  1 , Hiroaki Toba  1 , Ayaka Baba  1 , Emi Takehara  1 , Keisuke Fujimoto  1 , Taihei Takeuchi  1 , Hiroyuki Sumitomo  1 , Naoki Miyamoto  1 , Atsushi Morishita  1 , Naoya Kawakita  1 , Hiromitsu Takizawa  1
Affiliations
Case Reports

Real-Time Identification of Lymph Vessels Using Indocyanine Green in a Patient With Chylothorax Associated With Lymphangioleiomyomatosis

Shinichi Sakamoto et al. Asian J Endosc Surg. 2025 Jan-Dec.

Abstract

Introduction: Lymphangioleiomyomatosis (LAM) is often complicated by chylothorax and may require surgical intervention; however, the treatment is complicated because of difficulties in identifying the location of the fistula intraoperatively. This is the first report to identify the site of a chyle fistula associated with LAM in real time during surgery by using indocyanine green (ICG) lymphangiography.

Materials and surgical technique: A 56-year-old woman received a diagnosis of a treatment-resistant left chylothorax associated with LAM. To identify the chyle fistula during surgery, 1 mL of ICG (2.5 mg) was injected into both inguinal lymph nodes under ultrasound guidance after anesthesia, with 1 mL per side for a total of 5 mg of ICG. We performed video-assisted thoracic surgery and observed near-infrared light acquisition and overlay technology using Stryker. Approximately 1 h after administration, fluorescence was observed in the anterior mediastinal lymph nodes, and a chyle fistula was observed around them. Although we attempted ligation of the lymph trunk, the surgical procedure damaged well-developed lymph vessels. The damaged area and anterior mediastinal lymph nodes, including the surrounding lymph vessels, were incinerated using soft coagulation and covered with polyglycolic acid sheets and fibrin glue. Consequently, the amount of chylous effusion decreased.

Discussion: The use of ICG allowed visualization of the lymphatic pathway and location of the chyle fistula in real time during surgery, enabling precise local treatment to reduce chyle effusion.

Keywords: chylothorax; indocyanine green; lymphangioleiomyomatosis.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Chest radiograph revealed a left pleural effusion, and computed tomography revealed multiple thin‐walled cysts in both lung fields (white arrowheads).
FIGURE 2
FIGURE 2
Intraoperative indocyanine green (ICG) imaging of lymph node and lymph vessels (superior view). The anterior mediastinal lymph nodes and lymph vessels developed around them were fluorescent, and a chyle fistula was observed around them (inferior view).
FIGURE 3
FIGURE 3
Intraoperative surgical manipulation of the chyle fistula. We attempted to ligate the lymph trunk; however, the chyle effusion leaked from the developed lymphatic tissue (superior view). The chyle fistula was treated with soft coagulation, and the coagulated area was reinforced with a polyglycolic acid sheet and fibrin glue to prevent recurrence (inferior view).
FIGURE 4
FIGURE 4
Histological findings of the lymphangioleiomyomatosis (LAM) lesions in the lung. hematoxylin and eosin (H&E) staining (scale bars, 100 μm) revealed proliferation of spindle‐shaped LAM cells in multiple nodules in the lung tissue. Immunohistochemically, short spindle‐shaped cells are positive for α‐smooth muscle actin (α‐SMA) and human melanin black (HMB45) (scale bars, 100 μm).
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