Fluorescence image-guided lymphadenectomy using indocyanine green and near infrared technology in robotic gastrectomy (original) (raw)
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A pilot study of lymph node mapping with indocyanine green in robotic gastrectomy for gastric cancer
SAGE Open Medicine
Objectives: Robotic gastrectomy has become increasingly popular in the treatment of gastric cancer, especially in Asian countries. The use of indocyanine green fluorescence has been reported in lymphatic mapping for gastric cancer in laparoscopic gastrectomy; however, there have been few reports regarding the use of indocyanine green in robotic gastrectomy. Methods: From January 2011 to March 2016, a total of 79 patients underwent robotic gastrectomy for gastric cancer. Among them, intraoperative subserosal injection (n = 9) or preoperative submucosal injection (n = 5) of indocyanine green with near-infrared imaging was performed in 14 patients, and the other 65 patients underwent robotic gastrectomy without the use of indocyanine green. Results: There was no significant difference in the operative time, total number of retrieved lymph nodes, operative blood loss, and postoperative hospital stay between the patients who underwent robotic gastrectomy with or without indocyanine green fluorescence. For each lymph node station, there was significantly more number of retrieved lymph nodes in the indocyanine green group than in the no-indocyanine green group at the greater curvature side of the low body (#4d) to the infrapyloric region (#6) of the stomach. Five of the 14 patients who received an indocyanine green injection for lymphatic mapping had lymph node metastasis, and metastatic lymph nodes were located in the lymph node stations as detected by indocyanine green fluorescence during surgery. Conclusion: Indocyanine green fluorescence with near-infrared imaging is feasible and is a promising method of lymphatic mapping in robotic gastrectomy for gastric cancer. In future studies, larger patient numbers and long-term follow-up are required.
Journal of Gastrointestinal Surgery
Background Near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has been recently introduced for lymphatic mapping in several tumors. We aimed at investigating whether this technology may improve the intraoperative visualization of lymph nodes during robotic gastrectomy for gastric cancer. Methods Between June 2014 and June 2018, a total of 94 patients underwent robotic gastrectomy with D2 lymph node dissection for gastric cancer. In 37 patients, ICG was injected endoscopically into the submucosal layer around the tumor the day before surgery. After propensity score matching, the results of these 37 patients were compared with the results of 37 control patients who had undergone robotic gastrectomy without ICG injection. Results Among the 37 patients within the ICG group, no adverse events related to ICG injection or intraoperative NIR imaging occurred. After completion of D2 lymph node dissection, no residual fluorescent lymph nodes were left in the surgical field. A mean of 19.4 ± 14.7 fluorescent lymph nodes was identified per patient. The mean total number of harvested lymph nodes was significantly higher in the ICG group than in the control group (50.8 vs 40.1, P = 0.03). In the ICG group, 23 patients had metastatic lymph nodes. The accuracy, sensitivity, and specificity of ICG fluorescence for metastatic lymph nodes were 62.2%, 52.6%, and 63.0%, respectively. Conclusion Our study indicates that NIR imaging with ICG may provide additional node detection during robotic surgery for gastric cancer. Unfortunately, this technique failed to show good selectivity for metastatic lymph nodes.
Annals of Laparoscopic and Endoscopic Surgery
Lymphadenectomy for gastric cancer is considered to be technically difficult to perform in conventional laparoscopic surgery. The robotic system has been introduced to overcome some of these technical limitations of laparoscopy. The daVinci robotic platform allows near-infrared fluorescence imaging (NIFI) with indocyanine green (ICG) to be integrated into the surgical field. This pilot study aimed at investigating whether the use of NIFI with ICG may improve the intraoperative visualization of lymph nodes and help to identify complete lymph node removal during robotic gastrectomy. Fourteen patients underwent robotic distal gastrectomy with D2 lymph node dissection for gastric cancer. A 0.2% ICG solution was injected into the submucosa endoscopically at four sites around the tumor. Fluorescence imaging with ICG was carried out with a robotic infrared camera system. Fluorescent lymph nodes were both dissected out intraoperatively and isolated in the dissected specimen with the help of the robotic camera. Eight males and 6 females were enrolled in the study. No adverse effects of the ICG were observed. The mean total number of examined lymph node was 43.3 (range, 27-78). The mean number of fluorescent lymph nodes was 19.4 (range, 1-36). Seven patients were found to have metastatic lymph nodes: in 3 patients, all the metastatic lymph nodes were fluorescent, in 3 they were non-fluorescent and in 1 patient they were both fluorescent and non-fluorescent. NIFI is a promising method of lymphatic mapping during robotic gastrectomy and may provide a valuable adjunct for identification of complete D2 lymphadenectomy.
Annals of Coloproctology, 2021
Indocyanine green (ICG) could be applied for multiple functions such as fluorescent tumor localization, fluorescence lymph node mapping (FLNM), and intraoperative angiography in colorectal cancer surgery. With the near-infrared (NIR) systems, colonoscopic ICG tattooing can be used to define the early colorectal cancer that cannot be easily distinguished through the serosal surface. The lymphatic pathways can be visualized under the NIR system when ICG is injected through the submucosal or subserosal layer around the tumor. Intraoperative ICG angiography can be applied to find a favorable perfusion segment before the colon transection. Although all fluorescence functions are considered essential steps in image-guided surgery, it is difficult to perform multifunctional ICG applications in a single surgical procedure at once because complex protocols could interfere with each other. Therefore, we review the multifunctional ICG applications for fluorescent tumor localization, FLNM, and ...
Frontiers in Oncology, 2022
BackgroundThe near-infrared/indocyanine green imaging fluorescence (NIR/ICG) technology is showing promising results in several fields of surgical oncology. The clinical value of NIR/ICG technology in the surgical treatment of advanced gastric cancer (AGC) is not clearly established.MethodsThis is the protocol of the “iGreenGO” (indocyanine Green Gastric Observation) Study, a national prospective multicenter study. Western patients who undergo curative-intent gastrectomy with D2 lymphadenectomy for AGC constitute the study cohort. All the patients undergo preoperative upper gastrointestinal endoscopy for submucosal peritumoral ICG injection at the most 20 h before surgery. Intraoperative endoscopic injection before starting surgical dissection is also allowed. The primary endpoint is the “change in the surgical conduct” (CSC), i.e., the need to perform further dissection after intraoperative NIR/ICG technology activation at the end of D2 lymphadenectomy. Secondary endpoints include ...
New Intraoperative Imaging Tools and Image-Guided Surgery in Gastric Cancer Surgery
Diagnostics, 2022
Innovations and new advancements in intraoperative real-time imaging have gained significant importance in the field of gastric cancer surgery in the recent past. Currently, the most promising procedures include indocyanine green fluorescence imaging (ICG-FI) and hyperspectral imaging or multispectral imaging (HSI, MSI). ICG-FI is utilized in a broad range of clinical applications, e.g., assessment of perfusion or lymphatic drainage, and additional implementations are currently investigated. HSI is still in the experimental phase and its value and clinical relevance require further evaluation, but initial studies have shown a successful application in perfusion assessment, and prospects concerning non-invasive tissue and tumor classification are promising. The application of machine learning and artificial intelligence technologies might enable an automatic evaluation of the acquired image data in the future. Both methods facilitate the accurate visualization of tissue characteristi...
The Role of Indocyanine Green Fluorescence in Rectal Cancer Robotic Surgery: A Narrative Review
Cancers
Background: In rectal cancer surgery, anastomotic leakage (AL) remains the most feared complication, with a frequency of up to 30% in non-high-volume centers. The preservation of proper vascularization is a key factor for successful anastomosis. The use of fluorescence with indocyanine green (ICG) as an intraoperative method to verify optimal perfusion is becoming an interesting tool in rectal surgery. Today, robotic surgery, together with the use of the intraoperative evaluation of the perfusion with ICG, could be a real strategy to deal with AL, allowing for a more delicate and less traumatic surgical technique. This strategy may allow for an extremely accurate surgery, and for optimal control of the proper vascularization of the rectum. Methods: The purpose of this descriptive review is to analyze the impact of fluorescence and robotic surgery on short-term surgical outcomes for rectal cancer. Results: We performed a systematic literature search using the PubMed, Embase and Cochr...
Annals of Surgical Oncology, 2010
Objective: In this study, we determined the possible usefulness of sentinel node (SN) mapping guided by indocyanine green (ICG) fluorescence imaging in the management of gastric cancer. Summary Background Data: ICG fluorescence imaging system has recently been developed for obtaining biochemical information from living tissues. Methods: Our series consisted of 56 patients with gastric cancer who underwent standard gastrectomy with lymphadenectomy. Two milliliters of ICG solution (0.5%) was injected into the submucosa around the tumor endoscopically before the operation or into the subserosa intraoperatively. ICG fluorescence imaging was conducted using a charge-coupled device camera with a light-emitting diode having a wavelength of 760 nm as the light source and a cut filter to filter out light with wavelengths below 820 nm as the detector. Results: SNs were detected in 54 (96.4%) of the 56 patients, and the mean number of SNs was 7.2 Ϯ 7.0. Even SNs that were not green in color could be easily and clearly visualized by ICG fluorescence imaging. cT1-stage cancers were associated with a significantly higher accuracy rate (97.2% vs. 72.2%, P ϭ 0.0127) than cT2-or cT3-stage cancers. Preoperative ICG injection was associated with a significantly higher incidence of cT1-stage cancers (87.1% vs. 40.0%, P ϭ 0.0004), a larger mean number of SNs (9.9 Ϯ 7.5 vs. 4.1 Ϯ 5.0, P Ͻ 0.0001), a higher accuracy rate (100% vs. 73.9%, P ϭ 0.0039), and a lower false negative rate (0% vs. 60.0%, P ϭ 0.0345) as compared with intraoperative ICG injection. Conclusions: This study shows that ICG fluorescence imaging allows highly sensitive image-guided intraoperative SN mapping in cases of gastric cancer. Our data suggest that SN mapping guided by ICG fluorescence imaging might be useful for predicting the metastatic status in lymph nodes in cases of gastric cancer, especially those with cT1-stage cancer.
Journal of Surgical Oncology, 2009
Background: There has been a debate as to the extent of hepatic resection for T2 gallbladder cancer. While some surgeons advocate resection of the segments 4a and 5, gallbladder bed resection is also performed by others. A fluorescent imaging technique with selective injection of indocyanine green can provide real-time anatomic guidance within the operative field for hepatobiliary surgery. This study was performed to evaluate the usefulness of fluorescent navigation surgery for gallbladder cancer. Methods: Four patients underwent fluorescent navigation surgery for gallbladder cancer. As a source of fluorescence, indocyanine green was injected into the cystic artery. The liver surface was observed with a photodynamic eye and the perfusion area of indocyanine green was resected en bloc. All patients underwent lymph node dissection. Results: The patients comprised two men and two women with a mean age of 72 years. The mean operation time was 439.8 minutes, the mean blood loss was 504.5 ml, and the mean postoperative hospital stay was 16.5 days. The pathological tumor depth was T1b in one patient, T2 in two, and T3 in one. Lymph node metastasis was present in one patient. A negative surgical margin was obtained in all patients. The disease recurred in lymph nodes in the nodepositive patient and the remaining three patients are alive with no evidence of disease to date. Conclusions: Navigation surgery utilizing ICG fluorescence angiography via the gallbladder artery may provide a clue to the optimal areas of en bloc hepatic resection for T2 gallbladder cancer.
The Role of Indocyanine Near-Infrared Fluorescence in Colorectal Surgery
Frontiers in Surgery, 2022
The aim of this study was to evaluate the importance of Indocyanine Green in control of anastomosis perfusion and on anastomotic leakage rates during laparoscopic and robotic colorectal procedures. Methods: A retrospective review of patients who underwent elective minimally invasive surgery for colorectal cancer from 1 January 2018 to 31 December 2020 was performed. All patients underwent Near-Infrared Fluorescence-Indocyanine Green system in two moments: before performing the anastomosis and after completing the anastomotic procedure. Primary outcomes were the rate of intraoperative change in the surgical resection due to an inadequate vascularization and the rate of postoperative anastomotic leakage. Secondary outcomes were the postoperative complications, both medical and surgical (intra-abdominal bleeding, anastomotic leakage). Results: Our analysis included 93 patients. Visible fluorescence was detected in 100% of the cases. In 7 patients (7.5%), the planned site of resection was changed due to inadequate perfusion. The mean extension of the surgical resection in these 7 patients was 2.2 ± 0.62. Anastomotic leakage occurred in 2 patients (2.1%). Other complications included 8 postoperative bleedings (8.6%) and 1 pulmonary thromboembolism. Conclusions: The intraoperative use of Near-Infrared Fluorescence-Indocyanine Green in colorectal surgery is safe, feasible, and associated with a substantial reduction in postoperative anastomotic leakage rate.