Near-infrared fluorescent clip-guided navigation in robot-assisted thoracoscopic esophagectomy for esophageal cancer: a single-center feasibility study

Background In esophageal cancer surgery, ensuring a sufficient proximal margin without excessive resection is important for oncological safety and minimizing surgical difficulty in anastomosis. In robot-assisted surgery, direct tumor palpation is not possible, and conventional methods such as endoscopic tattooing or intraoperative endoscopy have certain limitations. This study aimed to evaluate the feasibility and clinical utility of a new near-infrared fluorescent clip (Xemex FS marker) for tumor localization during robot-assisted esophagectomy.

Methods This study included 60 consecutive patients with esophageal or esophagogastric junction cancer who underwent robot-assisted esophagectomy using the Xemex FS marker. In addition, 64 historical control patients who underwent robot-assisted esophagectomy without fluorescent clip-guided navigation were included for exploratory comparison of surgical margin outcomes. Two fluorescent clips were placed 1 cm oral to the tumor on the right side of the esophageal wall via endoscopy the day before surgery. The Firefly system of the da Vinci surgical system was used to confirm the clip location and determine the esophageal cutline. Surgical outcomes, complications, and proximal margin outcomes were evaluated.

Results Clip placement was successful in 59 of 60 patients (98.3%), and the fluorescent signal was detected intraoperatively in all 59 patients. No clip-related intraoperative complications were observed. The median proximal margin from the tumor was 52 mm in the fluorescent clip group and 48 mm in the control group, with no significant difference between the groups. Tumor exposure at transection was not observed in the fluorescent clip group, whereas it occurred in two patients in the control group. Intraoperative endoscopy was not required in any case in the fluorescent clip group.

Conclusions Near-infrared fluorescent clip navigation was feasible for intraoperative tumor localization during robot-assisted esophagectomy. This technique may improve surgical precision and simplify intraoperative workflow by eliminating the need for intraoperative endoscopy.