Lessons learned from routine thoracic duct visualization using high-fat ice cream during esophagectomy: insights from long-term clinical practice.

Reliable identification of the thoracic duct (TD) is critical during esophagectomy to prevent clinically significant chylothorax. Although various fat-loading and imaging techniques exist, many require specialized equipment or large-volume administration. We standardized a protocol using a small dose of high-fat ice cream administered three hours before anesthesia induction to facilitate lymphatic opacification. In our experience, this protocol was well-tolerated, without anesthesia-related adverse events, and achieved successful TD visualization in all cases without specialized imaging systems such as indocyanine-green fluorescence. Several practical lessons emerged from this decade-long experience. First, combined with thoracoscopic magnification, this approach enables reliable visualization down to the TD branches. This not only prevents inadvertent injury but also allows for the immediate identification and secure repair of any leakage. Second, preserving a clearly visualized TD was associated with fewer clinically relevant chyle leaks, even within a perioperative pathway incorporating very early enteral feeding. Third, TD preservation under direct visualization did not appear to compromise oncologic adequacy, with comparable survival and recurrence patterns in appropriately selected cases. In conclusion, safe intraoperative TD management may depend less on routine en bloc resection than on strategic preservation enabled by reliable visualization. This simple, widely accessible fat-loading protocol facilitates consistent TD identification, and supports selective preservation guided by oncologic considerations without increasing technical complexity. This practical framework enhances surgical safety and optimizes perioperative outcomes in modern esophageal surgery.