Analysis of chylous fistula sites and prevention of postoperative chylothorax in right lung cancer surgery using fluorescence thoracoscopy.

[OBJECTIVES] To analyze the common sites of chylous fistula in right lung cancer surgery and evaluate the effectiveness of chylothorax prevention using fluorescence thoracoscopy.

[METHODS] Patients who underwent right lung cancer resection at Beijing Hospital, between October 2023 and November 2024 were enrolled in the experimental group. Prior to thoracoscopy, a 0.4 mg/kg solution of indocyanine green was injected subcutaneously into the right inguinal region. Intraoperative visualization of the injuries to TD’s branches and selective fistula or TD ligation were recorded. Retrospective cases undergoing conventional thoracoscopic right lung cancer resection were enrolled as the control group. The incidence of postoperative chylothorax and clinical outcomes were compared between the two groups.

[RESULTS] A total of 202 patients were included in the experimental group. The TD was clearly identified in 168 patients (83.2%) within one hour after ICG injection. Collateral branch injuries were observed in 10 patients (9 in 2R + 4R and/or subcarinal regions, 1 in the anterior mediastinum). Among these 10 patients, 8 underwent TD ligation, while the remaining 2 received local fistula ligation. None of these patients developed chylothorax postoperatively. In the experimental group, only one patient (0.5%) developed postoperative chylothorax, and TD visualization was not achieved in this case. The control group comprised 227 patients, of whom 11 (4.8%) developed postoperative chylothorax. The incidence of chylothorax in the experimental group was significantly lower than that in the control group (1/202 vs. 11/227,  = 0.006). The postoperative duration of chest tube drainage and the length of hospital stay were also significantly shorter in the experimental group ( = 0.000 and  = 0.025, respectively). Multivariate logistic regression analysis revealed that not using the experimental surgical strategy ( = 0.021, OR 11.935, 95% CI: 1.443–98.702) and male sex ( = 0.020, OR 5.403, 95% CI: 1.300–22.456) were independent risk factors for postoperative chylothorax, while a higher BMI was a protective factor ( = 0.019, OR 0.826, 95% CI: 0.703–0.969).

[CONCLUSIONS] The 2R + 4R and subcarinal regions were the most common fistula sites in right lung cancer surgery. Fluorescence-guided selective fistula or TD ligation could reduce postoperative chylothorax risk.

[TRIAL REGISTRATION] This study was registered at the Chinese Clinical Trial Registry, and the registration number was ChiCTR2300076867.

[SUPPLEMENTARY INFORMATION] The online version contains supplementary material available at 10.1186/s12957-026-04248-z.