Indocyanine Green Group Research Articles

Meta-Analysis on the Efficacy of Indocyanine Green Fluorescence Angiography for Reduction of Anastomotic Leakage After Rectal Cancer Surgery.

Indocyanine green (ICG) fluorescence angiography is a new technique that help surgeons to assess the blood perfusion of the anastomotic intestine. The aim of this study is to evaluate whether ICG fluorescence angiography can reduce the anastomotic leakage (AL) rate after colorectal anastomoses for rectal cancer (RC) patients. Studies comparing AL rates between use and nonuse of ICG fluorescence angiography up to April 2020 were systematically searched from PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure. A pooled analysis was performed for the available data regarding the baseline features, AL rate, and other surgical outcomes. ReMan 5.3 software was used to perform the statistical analysis. Quality evaluation and publication bias were also conducted. Thirteen studies with a total of 2593 patients (1121 in the ICG group and 1472 in the control group) undergoing colorectal anastomoses after RC surgery were included. In the pooled analysis, the baseline data, operation time, and intraoperative blood loss in 2 groups were all comparable and without significant heterogeneity. However, the AL rate in the ICG group was significantly lower (OR .31; 95% CI .22-.44; P < .00001) than that in the control group. Additionally, ICG fluorescence angiography was associated with a decreased overall complication rate (OR .60; 95% CI .47-.76; P < .0001) in patients who undergo RC surgery. The present study revealed that ICG fluorescence angiography reduced AL rate after colorectal anastomoses for RC patients. However, more high-quality randomized controlled trials are needed to confirm this benefit.

Preoperative Colonoscopic Tattooing Using a Direct Injection Method with Indocyanine Green for Localization of Colorectal Tumors: An Efficacy and Safety Comparison Study.

PurposeEndoscopic tattooing is used to mark colorectal lesions for subsequent surgery. As a tattooing agent, India ink has been widely used but is not currently available in Korea. Indocyanine green (ICG) can be applied as an alternative agent. However, studies on colonoscopic tattooing by the direct injection of indocyanine green are lacking. This study aimed to compare the efficacy and safety between an ICG direct injection method and an India ink saline test injection method.MethodsA total of 227 patients who underwent preoperative endoscopic tattooing for colorectal neoplasm (149 patients in the ICG direct injection group and 78 patients in the India ink saline test injection group) were included in the study. The efficacy of the two methods was compared by visualization and safety was compared by evaluating the perioperative tattooing complications.ResultsThe visualization of lesions in the ICG group was not different from that of the India ink group (p=0.42, 96.0% vs 98.7%, respectively). Only one patient in the ICG group had abdominal pain related to tattooing, but no complications developed in the India ink group.ConclusionConsidering the good visualization and low complication rate, the direct injection of ICG can be used as an alternative tattooing method.

Comparisons of ICG-fluorescence with conventional tracers in sentinel lymph node biopsy for patients with early-stage breast cancer: A meta-analysis.

Radioisotopes (RI) and blue dye (BD) are routinely used markers for staining during sentinel lymph node biopsy (SLNB) in breast cancer. Compared with traditional tracers, tracer performance of indocyanine green (ICG) has been controversial. A total of 21 studies were selected from the PubMed, EMBASE and Cochrane Library databases. Detection ability was judged based on four endpoints: i) The identification rate (IR) of the patients; ii) the IR of the sentinel lymph nodes (SLNs); iii) the IR of the positive SLNs; and iv) the false negative rate (FNR). Compared with BD, ICG was superior in terms of the IR of the patients [odds ratio (OR)=7.17; 95% CI, 3.98-12.94), the IR of the SLNs (OR=8.84; 95% CI, 6.71-11.66) and FNR (OR=0.20; 95% CI, 0.08-0.48) using a fixed-effects model. There was a significant difference in both the IR of the positive SLNs (OR=21.32; 95% CI, 2.84-160.14) and FNR (OR=0.46; 95% CI, 0.23-0.91) in the ICG vs. RI group. Furthermore, when using ICG at the recommended dose, a significant difference was found in the IR of the patients (OR=1.77; 95% CI, 1.09-2.85) and the IR of the SLNs (OR=21.62; 95% CI, 5.23-89.43) using a fixed-effects model. In the ICG vs. BD combined with RI group, there were no differences in either the IR of the patients (OR=5.10; 95% CI, 0.24-107.48) or the IR of SLNs (OR=5.10; 95% CI, 0.60-256.66). In conclusion, ICG was a better tracer compared with BD or RI alone and was not a worse tracer compared with BD combined with RI. The use of the recommended dose of ICG had an improved tracer effect. ICG is expected to be widely used in SLNB in view of its clinical advantages.

Comparison of indocyanine green fluorescence and methylene blue dye in the detection of sentinel lymph nodes in breast cancer.

Previous studies have shown that sentinel lymph node biopsy (SLNB) can be successfully performed using methylene blue (MB); however, this method still has some drawbacks. Indocyanine green (ICG) fluorescence imaging, as a selective method, has the potential for guiding SLNB. This study aimed to compare the clinical sensitivity and efficacy between ICG and MB in SLNB in breast cancer. A prospective study of 70 patients with biopsy-proven invasive breast cancer was conducted. Under the guidance of ICG and MB, administered by injection, SLNs were examined and removed. The detection rates, total number of SLNs detected, mean number of SLNs detected, and number of positive SLNs were compared between ICG and MB. The SLN detection rate was 100% and 93% (65/70) for ICG and MB, respectively. More SLNs were detected in the ICG group (243) than in the MB group (169). The mean number of SLNs detected with ICG and MB was 3.5±1.73 and 2.4±1.49, respectively. Moreover, there was a statistically significant difference between the number of SLNs detected using the two methods (t=6.648, P<0.05). Additionally, SLN metastasis was detected in 18 patients using ICG and 14 patients using MB; these patients immediately underwent axillary lymph node dissection (ALND). No postoperative complications were reported. ICG demonstrated a higher detection rate and better accuracy, as well as a lower false negative rate, than MB in detecting SLNs in breast cancer. ICG has potential as an alternative tool that could be clinically applied to detect SLNs in breast cancer patients.

Intraoperative fluorescence angiography and risk factors of anastomotic leakage in mini-invasive low rectal resections.

One of the prerequisites for proper healing of the anastomosis after a colorectal resection is adequate blood supply to the connected intestinal segments. It has been proposed that adequate visualization of the blood flow using indocyanine green (ICG) could lead to the reduction in the incidence of anastomotic leakage (AL). The aim of this study was to assess the effectiveness of intraoperative fluorescence angiography (FA) in decreasing the incidence of AL after minimally invasive low anterior resection (LAR) with total mesorectal excision (TME) in rectal cancer patients and to determine predictors of anastomotic leak. From August 2015 to January 2019, data from 100 patients who underwent mini-invasive TME for rectal cancer using FA with indocyanine green (ICG) were prospectively collected and analyzed. They were compared with retrospectively analyzed data from a historical control group operated by one team of surgeons before the introduction of FA from November 2012 to August 2015 (100 patients). All patients from both groups were operated sequentially in one oncological center in Nový Jičín. The incidence of AL was significantly lower in the ICG group (19% vs. 9%, p = 0.042, χ2 test). In fifteen patients in the ICG group (15%), the resection line was moved due to insufficient perfusion. Using Pearson's χ2 test, diabetes (p = 0.036) and application of a transanal drain (NoCoil) (p = 0.032) were identified as other risk factors (RFs)for AL. The use of ICG to visualize tissue perfusion in low rectal resections for cancer can lead to a reduction of AL.

Assessment of intraoperative use of indocyanine green fluorescence imaging on the incidence of anastomotic leakage after rectal cancer surgery: a PRISMA-compliant systematic review and meta-analysis.

The current data on the intraoperative use of indocyanine green (ICG) fluorescence imaging to reduce the anastomotic leak (AL) rate in rectal cancer surgery remain controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ICG fluorescence imaging in decreasing the AL rate after rectal cancer surgery. Studies comparing ICG fluorescence imaging with standard care in patients with rectal cancer were systematically searched from PubMed, Embase, Web of Science and Cochrane Library through January 2020. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the baseline features, AL rate and other surgical outcomes. RevMan version 5.3 software was used for the present meta-analysis. Nine studies with a total of 2088 patients with rectal cancer (926 in the ICG group and 1162 in the control group) were included in the present study. In the pooled analysis, the available patient and tumour-related baseline data were all comparable and without significant heterogeneity. In the present pooled analysis, the AL rate in the ICG group was significantly lower (OR 0.34; 95% CI 0.22-0.52; p < 0.0001) than that in the control group. Additionally, intraoperative use of ICG was associated with a decreased overall complication rate (OR 0.57; 95% CI 0.42-0.78; p = 0.0003) and reduced reoperation rate (OR 0.26; 95% CI 0.08-0.86; p = 0.03) in patients who had rectal cancer surgery. The present study demonstrated the superiority of the intraoperative use of ICG in reducing the AL rate. However, considering the limitations of the included studies, more high-quality prospective studies and randomized controlled trials are needed.

Comparison of indocyanine green and methylene blue use for axillary reverse mapping during axillary lymph node dissection.

Axillary reverse mapping (ARM) is a technique to identify arm lymphatic drainage during axillary lymph node dissection (ALND). This study compared the feasibility of ARM using indocyanine green (ICG) or methylene blue (MB), and accessed the oncologic safety of the procedure. Overall, 158 patients qualified for ALND were enrolled. The characteristics of ARM‐identified nodes were recorded with ICG (n = 78) or MB (n = 80) visualization. Fine‐needle aspiration cytology (FNAC) of the nodes were performed and validated by histologic analysis. The nodal identification rate in the ICG group significantly surpassed that of the MB group (87.2% vs 52.5%, P < .05) with fewer complications. Note that 10.9% of the patients had metastatic involvement of the ARM‐identified nodes. Also 80% of the positive nodes were found in areas B and D, while the ARM‐identified nodes mainly located in area A. All the 51 nodes diagnosed as negative of malignancy by FNAC were free of metastasis. Nodal metastasis was significantly correlated with extensive nodel involvement, advanced disease, and the characteristics of identified nodes. In conclusion, ICG appears superior to MB for ARM nodes identification. FNAC, together with the features of primary tumors and ARM nodes, can delineate which nodes could be preserved during ALND.

Fluorescent cholangiography with direct injection of indocyanine green (ICG) into the gallbladder: a safety method to outline biliary anatomy.

Near infrared cholangiography (NIRC) with indocyanine green (ICG) directly injected into the gallbladder is a novel technique to outline biliary anatomy. The purpose of this article is to analyze the usefulness and feasibility of NIRC as a safety method during laparoscopic cholecystectomies. A case-controlled study comparing 20 patients undergoing laparoscopic cholecystectomies with NIRC with direct injection of ICG into the gallbladder to 20 consecutive standard cholecystectomies. Operative time, length of stay, complications, conversion rates, and biliary injury were analyzed. Both groups were comparable in epidemiological characteristics. In the ICG group fluorescent visualization of the junction of the Hartmann pouch and the whole cystic duct was achieved in 16 (80%) patients. Median surgical time was 65 (50-76) and 55 (45-71)min for the ICG and the control group, respectively (p = 0.113). There were no postoperative complications and no biliary duct injuries in any of the groups, and a patient from both groups underwent conversion to open surgery. NIRC with direct injection of ICG into the gallbladder is a feasible method that is not time-consuming; it does not require a different learning curve from standard laparoscopic cholecystectomies and has no major complications described so far.

Intraoperative indocyanine green fluorescence imaging in breast surgery

BackgroundSince postoperative complications after reconstructive breast surgery are often related to drastic increases of patient suffering and treatment costs, several devices were developed in order to avoid them. In this respect, the intraoperative fluorescence angiography with indocyanine green (ICG) provides promising results by detecting ischemic skin intraoperatively.MethodsWomen who underwent reconstructive breast surgery at the breast center at Charité between April and December 2017 were included in the analysis. General patient characteristics, medical history, type of surgery, as well as postoperative parameters, complications and patient reported outcomes were compared between patients operated using ICG fluorescence angiography and conventionally operated patients.ResultsAmong 68 patients with breast reconstruction 36 (52.9%) were operated with the ICG angiography device and 32 (47.1%) without. No significant differences regarding patient demographics, medical history, and surgical procedure were found. Wound healing disorders occurred in 11.1% of the ICG group and in 9.4% of the control group. About 11% of both groups developed major complications which required revision surgery. Complication rates and patient reported outcome did not differ significantly. Across both groups, only the risk factor resection weight (≥ 500 g) was significantly associated with wound healing disorders (RR = 6.80; 95%CI 1.93–23.81; p = 0.022).ConclusionThe purchase of a device for intraoperative ICG angiography might not be reasonable for every breast center. Further research in a larger cohort and prospective manner should be done to determine if the addition of ICG to breast reconstructive surgery in the German setting really leads to improved patient care.

Indocyanine green fluorescence angiography to evaluate anastomotic perfusion in colorectal surgery.

The aim of this study was to evaluate the efficacy of indocyanine green (ICG) fluorescence angiography with respect to the anastomotic leakage rate for patients undergoing colorectal operations. This prospective cohort involved patients who underwent colorectal surgery between August 2018 and September 2019. ICG was injected after colonic transection. Vascular perfusion was observed by ICG fluorescence system before completing anastomosis. Data was compared with those by subjective visual evaluation. The primary outcome was anastomotic leakage rate within 30days from surgery. A total of 131 patients were enrolled, of which ICG was injected in 63 of them. Demographic data were similar between the two groups. There were two (3.23%) and three (4.35%) anastomotic leaks in the ICG and non-ICG group respectively (p = 1.000). Change of resection plane occurred in one patient in the ICG group. There was no ICG related toxicity or adverse events. ICG fluorescent imaging is a feasible and safe tool to assess colonic vascularisation for patients undergoing colorectal surgery. However, it did not significantly lower the anastomotic leakage rate. ICG should not be routinely used in colorectal surgery before an available large scale randomised controlled trial to prove any clinical benefits.

Near-infrared fluorescence-guided surgery using indocyanine green facilitates secure infrapyloric lymph node dissection during laparoscopic distal gastrectomy.

We aimed to investigate the usefulness of near-infrared indocyanine green (ICG)-enhanced fluorescence guidance for infrapyloric LN dissection in laparoscopic distal gastrectomy. This study enrolled patients with early gastric cancer scheduled for laparoscopic distal gastrectomy. After intraoperative submucosal injection of ICG (0.1mg/mL), LN dissection was conducted under near-infrared ICG fluorescence guidance. The operation time, bleeding events during infrapyloric LN dissection were analyzed. Cases were retrospectively 1:3 propensity-score matched to patients who underwent laparoscopic distal gastrectomy without ICG injection. The mean time from midline omentectomy to exposure of the right gastroepiploic vein was significantly shorter in the ICG group (n = 20) than in the non-ICG group (n = 60) (13.05 ± 5.77 vs 18.68 ± 7.92min; p = 0.001), and the incidence of bleeding during infrapyloric LN dissection was lower in the ICG group (20% vs 68.3%, p < 0.001). The two groups did not differ significantly regarding the number of LNs retrieved from the infrapyloric area (p = 0.434). Near-infrared ICG fluorescence guidance facilitates safe and fast infrapyloric LN dissection in laparoscopic distal gastrectomy.

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer

The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial. To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer. Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019. The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery. Total number of retrieved lymph nodes. Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery. Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy. ClinicalTrials.gov Identifier: NCT03050879.

The impact of fluorescence angiography on anastomotic leak rate following transanal total mesorectal excision for rectal cancer: a comparative study.

Anastomotic leak (AL) is the most feared complication in colorectal surgery. Indocyanine green (ICG) fluorescence angiography allows for real-time intraoperative evaluation of bowel perfusion. This study aimed to assess the impact of ICG on perioperative outcomes in patients treated with transanal total mesorectal excision (TaTME) for rectal cancer. Comparative study based on a retrospective analysis of prospectively collected data, to validate the use of ICG assessment (ICGA) during TaTME (November/2011-June/2018). The primary outcome was the clinical AL rate. The secondary outcomes included modification of proximal colonic transection, anastomotic redo, additional surgical maneuvers and surgical morbidity. Two hundred and eighty-four patients were included, 204 (71.8%) in non-ICG group and 80 (28.2%) in ICG group. No significant differences were found in patient and tumor features. Mean anastomotic height was 4.85cm vs. 5.04cm (p = 0.500), diverting stoma was constructed in 205 patients (72.1% vs. 72.5%; p = 0.941). Fluorescence angiography modified the surgical plan in 23 patients (28.7%). AL was diagnosed in 23 patients (11.3%) in the non-ICG group and in two patients (2.5%) in the ICG group (p = 0.020). Postoperative intraabdominal collection was diagnosed in 19 patients (7.4% vs. 5.1%; p = 0.490), and reintervention was needed in 24 patients (10.8% vs. 7.6%; p = 0.420). Median length of hospital stay was 6.0 (IQR 5.0-9) vs. 4.0 (IQR 3.0-8.5) (p = 0.005). ICGA was found as independent protective factor for AL in the multivariate analysis of the whole cohort (n = 284) (OR 0.142; 95% CI 0.032-0.633; p = 0.010). ICG fluorescence angiography modified the proximal colonic transection in more than one-quarter of patients, leading to a significant decrease of AL rate.

Indocyanine green-enhanced fluorangiography (ICGf) in laparoscopic extraperitoneal rectal cancer resection.

Anastomotic leak (AL) is one of the worst complications of rectal anterior resection (RAR) and its incidence varies according to the anatomical site, increasing in lower anastomoses. Many etiological factors have been evaluated and most of these are related to bowel perfusion. Indocyanine green-enhanced fluorangiography (ICGf) has been proposed to help surgeons assess colonic perfusion with higher reliability than subjective clinical judgment. The aim of the study was to evaluate the efficacy of this tool in patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer. All the patients subjected to elective laparoscopic RAR for extraperitoneal rectal cancer between May 2015 and January 2017 were considered. In all of them, ICGf was performed to evaluate bowel perfusion. The control group included an equal number of patients subjected to the same procedure from January 2014 to April 2015, before the start of routine use of this tool at our institution. The endpoint of the study was to compare the incidence of AL between the two groups. A total of 33 patients were included in both groups. Relying on fluorescence intensity in the indocyanine green (ICG) group, we changed the level of resection in 6/33 patients (18.2%). An AL developed in 2/33 patients (6%) in the ICG group versus in 7/33 patients (21.2%) in the control group. The routine use of this technique may help surgeons in selecting the best level of proximal bowel resection during RAR.

The safety and feasibility of intraoperative near-infrared fluorescence imaging with indocyanine green in thoracoscopic sympathectomy for primary palmar hyperhidrosis.

BackgroundWe investigated the safety and feasibility of intraoperative near‐infrared (NIR) imaging using indocyanine green (ICG) during sympathectomy in the management of primary palmar hyperhidrosis (PPH).MethodsWe performed a retrospective review of 142 patients (ICG group) who underwent endoscopic thoracic sympathectomy (ETS) between February 2018 and April 2019. All patients received a 5 mg/kg infusion of ICG 24 hours preoperatively. The vital signs before and after ICG injection and adverse reactions were recorded. Meanwhile, 498 patients (Non‐ICG group) who underwent ETS by normal thoracoscopy during August 2017 to April 2019 were also reviewed to compare the abnormal white blood cell (WBC) counts, alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), and creatinine (Cr) levels before and after operation between two groups.ResultsFor ICG group, the vital signs including body temperature, heart rate and blood pressure before and after ICG injection were stable. There was no significant difference in the abnormal WBC counts, ALT, AST, BUN, and Cr levels before and after operation between two groups. Only one patient had mild adverse reaction (0.7%) after ICG injection. The visibility rate of all sympathetic ganglions was 96.7% (1369/1415). The visibility rate from T1 to T5 was 98.23% (278/283), 98.23% (278/283), 97.17% (275/283), 95.76% (271/283), and 94.35% (267/283), respectively. There was no significant difference in the visibility rate with regard to age, gender, height, weight, body mass index, and PPH grade.ConclusionsNIR fluorescence imaging with ICG for identifying sympathetic ganglions is relatively safe and feasible.Key points• Significant findings of the study. NIR fluorescence imaging with ICG for identifying sympathetic ganglions is relatively safe and feasible.• What this study adds.This technology may take the place of the rib‐oriented method as standard practice for the precise localization of sympathetic ganglions, and may improve the effect of sympathectomies.

Application of Near-Infrared Fluorescence Imaging with Indocyanine Green in Totally Laparoscopic Distal Gastrectomy.

PurposeRecently, totally laparoscopic gastrectomy has been gradually accepted by surgeons worldwide for gastric cancer treatment. Complete dissection of the lymph nodes and the establishment of the surgical margin are the most important considerations for curative gastric cancer surgery. Previous studies have demonstrated that indocyanine green (ICG)-traced laparoscopic gastrectomy significantly improves the completeness of lymph node dissection. However, it remains difficult to identify the tumor location intraoperatively for gastric cancers that are staged ≤T3. Here, we investigated the feasibility of ICG fluorescence for lymph node mapping and tumor localization during totally laparoscopic distal gastrectomy.Materials and MethodsPreoperative and perioperative data from consecutive patients with gastric cancer who underwent a totally laparoscopic distal gastrectomy were collected and analyzed. The patients were categorized into the ICG (n=61) or the non-ICG (n=75) group based on whether preoperative endoscopic mucosal ICG injection was performed.ResultsThe ICG group had a shorter operation time and less intraoperative blood loss. Moreover, significantly more lymph nodes were harvested in the ICG group than the non-ICG group. No pathologically positive margin was found and there was no significant difference in either the proximal or distal surgical margins between the 2 groups.ConclusionsNear-infrared fluorescence imaging with ICG can be successfully used in totally laparoscopic distal gastrectomy, and it contributes to both the completeness of D2 lymph node dissection and confirmation of the gastric transection line. Well-designed prospective randomized studies are needed in the future to fully validate our findings.

Feasibility and efficacy of indocyanine green used in laparoscopic gastrectomy for advanced gastric cancer patients

Objective: To identify the feasibility and efficacy of indocyanine green (ICG) used in laparoscopic gastrectomy for advanced gastric cancer patients. Methods: From December 2018 to August 2019, the clinical data of 82 patients preoperatively diagnosed as advanced gastric cancer undergoing laparoscopic radical gastrectomy were retrospectively analyzed. These patients were divided into ICG group(n=38) and a historical control group (non-ICG group, n=44). The number of retrieved lymph nodes, operation time, blood loss, hospital stay, fever time, evacuation time and complications were compared between these two groups. Results: The operation time [(172.8±45.8) min vs (162.6±45.7) min], blood loss [(80.1±91.9) ml vs (78.6±89.8) ml], hospital stay [(7.0±2.0) d vs (7.5±2.4) d], fever time [(2.3±1.2) d vs (2.9±1.9) d], evacuation time [(3.4±0.8) d vs (3.4±1.1) d] and incidence of complications (5.3% vs 9.1%) were not significantly different between the ICG and historical control groups (P>0.05). The number of retrieved lymph nodes in ICG group was significantly increased compared with that of the historical control group (46.5 vs 33.0, P=0.005). Conclusions: The ICG method applied in lymph node dissection of laparoscopic radical gastrectomy is safe. Moreover, ICG might elevate the efficiency of regional lymph node dissection.

Efficacy of indocyanine green fluorescence angiography in preventing anastomotic leakage after laparoscopic colorectal cancer surgery.

Some recent studies have suggested that fluorescence angiography with indocyanine green (ICG) might be useful for preventing anastomotic leakage (AL) after laparoscopic colorectal surgery. However, its efficacy has not been proven. We evaluated whether intraoperative ICG fluorescence angiography could decrease the AL rate with laparoscopic colorectal cancer surgery. This retrospective study included patients with colorectal cancer who underwent laparoscopic surgery at our institution between March 2014 and December 2018. Patients were divided into two groups: with or without ICG fluorescence angiography. The primary outcome was the rate of AL. A total of 488 patients were included: 223 patients in the ICG group and 265 patients in the no-ICG group. In the ICG group, the transection line was changed to a more proximal location in seven patients (3.1%), including one patient with transverse colon surgery and six with rectal surgery. None of these seven patients developed AL. There were 18 ALs (3.7%) overall. The AL rate was 1.8% in the ICG group and 5.3% in the no-ICG group. For colon cancer, there were no significant differences in the AL rate between the groups (p = 0.278). In rectal cancer, the AL rate was significantly lower in the ICG group than in the no-ICG group (3.5% vs. 10.5%, p =0.041). After propensity score matching, the AL rate was also significantly lower in the ICG group for rectal cancer (p =0.044). ICG fluorescence angiography can potentially reduce the AL rate with laparoscopic rectal cancer surgery.

Clinical effectiveness of indocyanine green mediated antimicrobial photodynamic therapy as an adjunct to scaling root planing in treatment of chronic periodontitis- A randomized controlled clinical trial.

Antimicrobial photodynamic therapy (aPDT) along with scaling and root planing has been studied for treatment of periodontitis. Various photosensitizers have been utilized for the same. The present study was conducted to assess the clinical efficacy of indocyanine green (ICG), a photosensitizer with better tissue absorption and low toxicity, as an aPDT adjuvant to scaling and root planing (SRP). In the present split-mouth clinical study 29 patients suffering from chronic generalized periodontitis were enrolled. The test and control quadrant were randomly allocated, control quadrant was treated with scaling and root planing alone, while the test group received an adjunctive therapy in the form of ICG, mediated aPDT along with SRP. Clinical parameters such a plaque index (PI), modified sulcular bleeding index (mSBI), periodontal probing depth (PPD) and clinical attachment level(CAL)were recorded at baseline and 3 months. It was observed that there was a significant reduction in PI and mSBI from baseline to 3 months in both the groups, although, the intergroup comparison for both parameters yielded a non-significant result. Whereas a significant improvement in PPD and CAL in ICG group were recorded during the intergroup comparison between test and control group from baseline to 3 months CONCLUSION: Within the limits of the present study it can be concluded that ICG mediated PDT when used as an adjunct improved the effectiveness of SRP.

P2.17-12 Robotic Assisted Segmentectomy - Intravenous vs Intrabronchial Fluorescence Thoracoscopy to Identify the Intersegmental Plane

Increasingly earlier detection of small lung cancers may permit the possibility of anatomical sublobar resection. Robotic assisted thoracic surgery (RATS) facilitates complex segmentectomy but identification of the intersegmental boundary remains a drawback to minimally invasive techniques. We have employed two contrasting methods using either intravenous (IV) or intrabronchial (IB) indocyanine green (ICG) and compared the efficacy. The location of the lesion was identified on CT reconstruction. Patients were allocated to either method by surgeon preference. IV ICG was injected during RATS after division of the target segmental artery. A novel aerosolized IB technique (by fibreoptic bronchoscopy) was used to inject the target segmental bronchus before RATS. All operations were performed using the Da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) and near infrared thoracoscopy (Firefly®). IV ICG was administered in 18 patients and IB ICG was given in 13 patients. The intersegmental plane was identified by the fluorescence demarcation line, which was then divided using the robotic stapler. On univariate analysis, there were no intergroup differences between IV and IB in the patient demographics (median age 70.5 years vs 71 years), number of staple firings (8 vs 10, p>0.05), success in identifying the intersegmental plane (94 vs 100% respectively, p>0.05), postoperative air leak duration (2 vs 3 days, p >0.05), or TNM staging of tumours (T1 64% vs 86% respectively, p>0.05). The total anaesthetic time (230 vs 290 mins, p<0.05) and the operative duration (171.5 vs 193.5 mins, p<0.05) were significantly less in the IV ICG group. In IB ICG, more than half of the segmentectomies involved the apical segment of either lower lobe (5 R S6, 1 L S6; 3 L S1-3, 2L S4-5), whereas in IV ICG more complex segmentectomies were performed (2 R S1-2, 2 R S6, 2 R S7-10; 2 L S1-2, 5 L S1-3, 2 L S4-5, 1 L S7-10, 1 L S7-8). There was no mortality nor major complications in either group. One case was converted to thoracotomy due to extensive adhesions in the IV ICG group. In the same group, there was one R1 resection due to parietal pleura involvement.TableComparison between IV and IB ICG in RATS segmentectomiesTotal number of patientsIV ICG (n=18)IB IVG (n=13)Excluded patients1 case converted to thoracotomy1 wedge resection (frozen section negative)1 lobectomy (abnormal anatomy)Patient age (median, range)70.5 (35-84)71 (50-89)Sex (M/F)11/77/6Target segments (R/L)R S1-2 2R S6 2R S7-10 2L S1-2 2L S1-3 5L S4-5 2L S7-10 1L S7-8 1R S6 5L S1-3 3L S4-5 2L S6 1Operative duration (median, range)171.5 mins (111-228)193.5 mins (178-275)No of staple firings (median, range)8 (2-14)10 (7-15)Success in identifying the intersegmental plane (%)16/17 (94%)11/11 (100%)Major complications00Conversion to VATS or open1(adhesions)0Tumour clearance (%)R0 16/17 (94%)R0 11/11 (100%)NSCLC (%)NSCLC 14/17 (82%)NSCLC 7/11 (63%)T-status in NSCLC (%)T1 9/14 (64%)T1 6/7 (86%) Open table in a new tab In RATS segmentectomy, identification of the intersegmental plane is facilitated by the intraoperative use of ICG. Both IV and IB routes are feasible with comparable results. As the IV route appears to reduce the use of theatre time, a future randomized comparison is suggested.