Comparison of indocyanine green-near-infrared fluorescence guided lymphadenectomy with conventional white light lymphadenectomy in patients undergoing thoraco laparoscopic esophagectomy for esophageal and gastroesophageal junction cancers- A open label, randomized control trial

Esophageal cancer (EC) is one of the most aggressive gastrointestinal malignancies. Patients often present with an advanced disease stage, encompassing metastatic lymph nodes or distant metastases, with a 5-year overall global survival rate of 15%–25% .(1, 2)Esophageal cancer ranks as the seventh most common cancer worldwide and the sixth leading cause of cancer-related mortality. Tumor histology, the location of the initial tumor, the T-stage, and neoadjuvant therapy all influence the location of metastatic lymph nodes [3]. Despite advancements in early detection and treatment, EC morbidity and mortality rates remain concerning, largely attributed to lymph nodes (LN). There is no consensus regarding the number of lymph nodes required for adequate staging. Some studies have concluded that the number depends on T staging and others > 23 for appropriate staging.(4) Indocyanine green (ICG) is a water-soluble dye with a molecular weight of 776 Da. ICG- near-infrared (NIR) fluorescence imaging has become a novel surgical navigation technology for surgical treatment. ICG injected into submucosa, travels along the lymphatics to reach the regional lymph nodes. ICG emits green fluorescence which can be identified by near infra-red light. This property of ICG can be explored to gain adequate lymph node retrieval during lymphadenectomy. RATIONALE: Lymph node metastasis is a major prognostic indicator of EC and GastroEsophageal Junction (GEJ) Cancers. Indocyanine green (ICG) ICG-NIR lymphadenectomy helps in easy identification of the draining lymph nodes and potentially increases the yield of number of lymph nodes dissected during esophagectomy. ICG-NIR. may potentially reduce operative time compared to conventional lymph node dissection. 

NOVELTY:  There are only 2 studies comparing the use of the ICG in lymphadenectomy of the esophagus and GEJ cancers. There are no studies done in India. EXPECTED OUTCOME: Lymphadenectomy done using ICG-NIR guidance will increase the number of lymph nodes retrieved, thereby helping in appropriate staging and prognosticating the patient.