Elsevier

Oral Oncology

Volume 78, March 2018, Pages 52-55
Oral Oncology

Real time indocyanin green near infrared lymphangiography for the reduction of drainage volume after neck dissection

https://doi.org/10.1016/j.oraloncology.2018.01.006Get rights and content

Highlights

  • High lymphatic drainage volume prolongs hospital stay after neck dissection.

  • Intra-operative ICG lymphangiography allows the detection of lymphatic leakage.

  • Accurate location of the site of lymphatic leakage allows precise repair.

  • Repair of lymphatic leakage significantly reduces drainage volume after surgery.

Abstract

Background

To investigate the role of indocyanine green (ICG) lymphangiography in the reduction of drainage after neck dissection.

Methods

Patients with oral cavity squamous cell carcinoma were randomized into Group A (study group) and Group B (control). In the study group, upon the completion of neck dissection, a total of 2.5 mg of ICG was injected submucosally at the four quadrants around the tumour. Another 2.5 mg of ICG was injected subdermally in the groin bilaterally. The neck was screened using Near Infrared fluorescence. The presence of lymphatic leakage was noted and plicated with silk stitches. The total drainage volume of post-operative day 1, day 2 and the total accumulated volume until drain removal was measured.

Results

Twenty-two patients (Group A, n = 12; Group B, n = 10) were recruited. All patients in Group A had at least one site of lymphatic leakage identified. One patient in Group B developed chylous fistula and was excluded from analysis. The mean total drain output for day 1 and 2 after surgery, as well as the mean total output before drain removal, were significantly lower in Group A (22.4 ml vs. 86.2 ml [p = .02]; 14.2 ml vs. 72.8 ml [p = .02]; and 58.4 ml vs. 392 ml [p = .01], respectively), allowing earlier drain removal (2.2 days vs. 7.2 days, p = .02).

Conclusions

Intra-operative ICG lymphangiography is useful in the reduction of drainage volume after neck dissection for caners in the head and neck region.

Introduction

Neck dissection is an integral part of the surgical treatment for cancers in the head and neck region. The presence of lymph node metastasis, especially those with extra-capsular spread, is shown to have a negative impact on the survival outcome after treatment, warranting aggressive therapeutic neck dissection followed by adjuvant chemoradiation. On the other hand, in patients with clinically N0 necks, elective selective neck dissections are frequently performed for better staging of the cervical nodal status [1].

Among the various complications of cervical lymphadenectomy, seroma and chyle fistula formation has received much attention [2]. Various local strategies [3], [4] and systemic administration of pharmacological agents [5], [6] have been studied, with various efficacy as well as adverse events associated with each method.

Since the first human test using indocyanine green (ICG) in 1957, its applications in hepatology, cardiology, urology and ophthalmology are well established. Recently, improving photometric detection of ICG opens the door to real time intra-operative angiography and lymphoscintigraphy. The current study investigates the potential role of using ICG fluorescence imaging in minimizing the risk of seroma and chyle fistula after neck dissection.

Section snippets

Patients and methods

The study was approved by the Institutional Review Board of the University of Hong Kong and the Hospital Authority, Hong Kong West Cluster. Between 2016 and 2017, consecutive patients with squamous cell carcinoma (SCC) in the head and neck region who required modified radical neck dissection (mRND) for the treatment of cytologically proven metastatic cervical lymph nodes were recruited. Patients with previous radiotherapy or surgery to the neck, as well as those with known allergy to ICG were

Results

During the study period, a total of 22 consecutive patients with SCC of the head and neck region were recruited into the study. Table 1 showed the demographics and tumour characteristics of the study subjects. The mean age of our patients was 64.2 years (range 48–74 years). Their mean body BMI was 22.7 kg/m2 (range 18.2–26.4 kg/m2). After randomization, 12 patients were allocated into Group A and the rest into Group B.

All patients in Group A had at least one site of lymphatic leakage identified

Discussion

Treatment of the neck is the integral part of the management for cancers in the head and neck region. The status of the regional lymphatics is one of the most important prognostic factors for these patients. Systematic removal of metastatic and potentially involved lymph nodes in the lateral neck became a routine in the surgical treatment after the procedure was described by Crile [7] and subsequently popularized by Martin [8]. Over the years, variants of the radical procedure were described,

Conclusions

Intra-operative real time ICG near infrared lymphangiography is feasible and useful in the reduction of drainage volume after neck dissection for caners in the head and neck region.

Conflict of interest disclosures

The authors have no conflict of interest to declare.

Financial disclosure

The authors confirm that there is no financial interest in the production of this work and there is no financial relationship or commercial association with the manufacturer that might pose a conflict of interest.

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