Indocyanine Green Group Research Articles

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.

The Clinical Value of Fluorescent Lymphography with Indocyanine Green During Robotic Surgery for Gastric Cancer: a Matched Cohort Study

BackgroundNear-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. MethodsBetween 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. ResultsAmong 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. ConclusionOur 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.

Application of indocyanine green-enhanced near-infrared fluorescence-guided imaging in laparoscopic lateral pelvic lymph node dissection for middle-low rectal cancer.

BACKGROUNDAs one effective treatment for lateral pelvic lymph node (LPLN) metastasis (LPNM), laparoscopic LPLN dissection (LPND) is limited due to the complicated anatomy of the pelvic sidewall and various complications after surgery. With regard to improving the accuracy and completeness of LPND as well as safety, we tried an innovative method using indocyanine green (ICG) visualized with a near-infrared (NIR) camera system to guide the detection of LPLNs in patients with middle-low rectal cancer.AIMTo investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer.METHODSA total of 42 middle-low rectal cancer patients with clinical LPNM who underwent total mesorectal excision (TME) and LPND between October 2017 and March 2019 at our institution were assessed and divided into an ICG group and a non-ICG group. Clinical characteristics, operative outcomes, pathological outcomes, and postoperative complication information were compared and analysed between the two groups.RESULTSCompared to the non-ICG group, the ICG group had significantly lower intraoperative blood loss (55.8 ± 37.5 mL vs 108.0 ± 52.7 mL, P = 0.003) and a significantly larger number of LPLNs harvested (11.5 ± 5.9 vs 7.1 ± 4.8, P = 0.017). The LPLNs of two patients in the non-IVG group were residual during LPND. In addition, no significant difference was found in terms of LPND, LPNM, operative time, conversion to laparotomy, preoperative complication, or hospital stay (P > 0.05).CONCLUSIONICG-enhanced NIR fluorescence-guided imaging could be a feasible and convenient technique to guide LPND because it could bring specific advantages regarding the accuracy and completeness of surgery as well as safety.

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis.

Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) andintraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87). This study suggests that intraoperative testing fora good blood supply using ICG may reduce the AL rate following colorectal surgery.

Application value of indocyanine green fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer

Objective To investigate the application value of indocyanine green(ICG) fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 702 patients with primary gastric cancer who underwent laparoscopic radical gastrectomy and D2 lymphadenectomy in the Fujian Medical University Union Hospital between April and December 2017 were collected. There were 517 males and 185 females, aged from 22 to 91 years, with an average age of 61 years. Of the 702 patients, 39 using ICG fluorescence imaging in the surgery and 663 not using ICG fluorescence imaging were allocated into ICG group and non-ICG group, respectively. Observation indicators: (1) surgical situations and postoperative recovery; (2) postoperative complications; (3) average number of lymph node dissected and positive lymph nodes; (4) follow-up situations. The number of lymph node dissected in the first station (No.1-7 group) and second station (No.8-12 group) were analyzed respectively. Follow-up using outpatient examination and telephone interview was performed to detect complications of patients up to June 2018. Measurement data with normal distribution were represented as Mean±SD, comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M (range), comparison between groups was analyzed using the Mann-Whitney U test. Count data were represented as absolute number or percentage, comparison between groups was analyzed using the chi-square test. Comparisons of ordinal data were analyzed by the Mann-Whitney U test. Results (1) Surgical situations and postoperative recovery: 702 patients underwent successfully laparoscopic radical gastrectomy and D2 lymphadenectomy, without injuries of important vessels and adjacent organs, without combined multiple organs resection or conversion to open surgery. Of 39 patients in the ICG group, cases undergoing total radical gastrectomy, distal subtotal gastrectomy and proximal subtotal gastrectomy, cases with Roux-en-Y esophagojejunostomy, Billroth Ⅰ anastomosis, Billroth Ⅱ anastomosis, Roux-en-Y gastrojejunostomy and esophagogastric anastomosis, operation time, volume of intraoperative blood loss, time for out-of-bed activities, time to initial anal exsufflation, time to first fluid diet intake and duration of postoperative hospital stay were 21, 16, 2, 21, 3, 13, 2, 0, (173±28)minutes, 40 mL(range, 5-200 mL), (2.1±0.6)days, (3.5±1.4)days, (4.8±1.3)days, (8.6±3.6) days. The above indexes were 363, 299, 1, 363, 27, 267, 1, 5, (174±41)minutes, 50 mL(range, 0-1 750 mL), (2.2±0.8)days, (3.4±1.1)days, (4.6±1.5)days, (9.4±5.0)days in the non-ICG group. There were statistically significant differences in the surgical type and digestive reconstruction method (χ2=9.550, 11.388, P 0.05). (2) Postoperative complications: 92 out of the 702 patients had postoperative complications, without death of complications. The incidence of complication was 15.38%(6/39) and 12.97%(86/663) in the ICG group and non-ICG group, with no statistically significant difference between the two groups (χ2=0.188, P>0.05). Six patients with complications (1 of Clavien-Dindo Ⅳ, 2 of Clavien-Dindo Ⅲa, 3 of Clavien-Dindo Ⅰ) in the ICG group and 86 (6 of Clavien-Dindo Ⅳ, 16 of Clavien-Dindo Ⅲ, 61 of Clavien-Dindo Ⅱ, 3 of Clavien-Dindo Ⅰ) in the non-ICG group were cured after symptomatic treatment. (3) Average number of lymph node dissected and positive lymph nodes: the average number of lymph node dissected and positive lymph nodes was 37 (range, 3-112) and 1 (range, 0-68) of 702 patients, 38 (range, 24-70) and 2 (range, 0-42) in the ICG group, 37 (range, 3-112) and 1 (range, 0-68) in the non-ICG group, with no statistically significant difference between the two groups (Z=-1.454, -0.514, P>0.05). Stratified analysis: the average number of No.1-7 group lymph nodes dissected and positive lymph nodes was 34 (range, 16-67) and 2 (0-38) in the ICG group, 33 (range, 3-91) and 1 (range, 0-56) in the non-ICG group. The average number of No.8-12 group lymph nodes dissected and positive lymph nodes was 11 (range, 4-22) and 0 (range, 0-13) in the ICG group, 9 (range, 0-31) and 0 (range, 0-25) in the non-ICG group. There was a statistically significant difference in the average number of No.8-12 group lymph nodes dissected between the two groups (Z=-1.984, P 0.05). (4) Follow-up situations: 702 patients were followed up for 6-14 months, with a median time of 10 months. There was no readmission caused by postoperative complications in the two groups. Conclusion ICG fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer is beneficial to dissection of perigastric lymph nodes and increase number of lymph nodes dissected, but cannot increase operation time and incidence of postoperative complications. Key words: Gastric neoplasms; Gastric cancer; Indocyanine green; Fluorescence imaging; Surgical safety; Laparoscopy

Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P<0.05 was considered statistically significant. A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5cm) ureteric resection. The median follow-up was 14 and 12months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P=0.020 and P=0.013, respectively). The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings.

Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis.

Fluorescent imaging using indocyanine green (ICG) is an emerging technique that aids the surgeon with intraoperative decision making during upper gastrointestinal cancer surgery. In this systematic review we aim to provide an overview of current practice of fluorescence imaging using ICG during esophagectomy, and to show how this technology can prevent surgical morbidity, such as anastomotic leakage, graft necrosis and chylothorax. The PRISMA standard for systematic reviews was used. The PubMed and Embase database were searched to identify articles matching our systematic literature search. Two authors screened all included articles for eligibility. Risk of bias was assessed for all included articles. A total of 25 articles were included in this review: 22 articles on perfusion assessment, and three on the detection of chyle fistula. Five out of 22 articles concerning perfusion assessment evaluated fluorescence signals in quantitative values. In 20 articles the pooled incidence of anastomotic leakage and graft necrosis in the ICG group was 11.10% (95% CI: 8.06-15.09%) and in eight studies the pooled change in management rate was 24.55% (95% CI: 19.16-30.88%). After change in management, the pooled incidence of anastomotic leakage and graft necrosis was 14.08% (95% CI: 6.55-27.70%). A meta-analysis showed that less anastomotic leakages and graft necrosis occur in the ICG group (OR 0.30, 95% CI: 0.14-0.63). Three case-reports (N=3) were identified regarding chyle fistula detection, and ICG lymphography detected the thoracic duct in all cases and the chyle fistula in one case. Fluorescence imaging using ICG is a promising and safe technology to reduce surgical morbidity after esophagectomy with continuity restoration. ICG fluorescence angiography showed a reduction in anastomotic leakage and graft necrosis. Future studies are needed to demonstrate the feasibility of ICG lymphography for chyle fistula detection.

PS01.193: VISUALIZED EVALUATION OF BLOOD FLOW TO THE GASTRIC CONDUIT CONTRIBUTES TO REDUCTION OF COMPLICATION IN ESOPHAGEAL RECONSTRUCTION

Abstract Background Evaluation of the blood supply to gastric conduits is critically important to avoid complications following esophagectomy. We commenced visualized evaluation of blood flow using indocyanine green (ICG) fluorescent imaging from July 2015, to reduce reconstructive complications. In this study, we aimed to statistically verify the efficacy of blood flow evaluation using our simplified ICG method. Methods We analysed and compared two groups, those before and after introduction of ICG evaluation. We performed propensity score matching (PS-M), compared clinical outcomes and analysed how the visualized evaluation reduced the risk of complications. Results Sixty-eight matched pairs were analysed. The leakage rate in the ICG group was significantly lower than the non-ICG group for each severity grade both in the entire cohort (285 subjects) and after PS-M, while the rate of other major complications, including recurrent laryngeal nerve (RLN) palsy and pneumonia, were not different between the two groups in the entire cohort and after PS-M. The duration of postoperative intensive care unit (ICU) stay was approximately one day shorter in the ICG than the non-ICG group in the entire cohort, and approximately two days shorter after PS-M. Visualized evaluation of blood flow with ICG methods significantly reduced the rate of anastomotic complications of all Clavien-Dindo (CD) severity grades. Odds ratio with ICG evaluation decreased with CD grade (0.3419 for CD ≥ 1, 0.241 for CD ≥ 2 and 0.2153 for CD ≥ 3). Conclusion Objective evaluation of blood supply to the reconstructed conduit using ICG fluorescent imaging reduces the risk and degree of anastomotic complication. Disclosure All authors have declared no conflicts of interest.

The Feasibility and Safety of Preoperative Fluorescence Marking with Indocyanine Green (ICG) in Laparoscopic Gastrectomy for Gastric Cancer

BackgroundSecuring the surgical margin is the most essential and important task in curative surgery. However, it is difficult to accurately identify the tumor location during laparoscopic surgery for gastric cancer, and existing methods, such as preoperative endoscopic marking with tattooing and clipping, have multiple disadvantages. AimsWe investigated the feasibility and safety of indocyanine green (ICG) fluorescence marking for determining the tumor location during laparoscopic gastrectomy. MethodsWe retrospectively analyzed preoperative and perioperative data from consecutive patients with gastric cancer undergoing planned laparoscopic distal gastrectomy. Data was maintained in a prospectively compiled surgical database, and patients were categorized into ICG (n = 84) or non-ICG (n = 174) groups based on whether they underwent preoperative endoscopic mucosal ICG injection. One-to-one propensity score matching (PSM) was performed to compare outcomes between the two groups. ResultsWe included 84 patient pairs after PSM, and there were no significant differences in preoperative patient characteristics. The ICG group had shorter procedure time (p < 0.001), lower estimated blood loss (p = 0.005), and significantly shorter postoperative hospital stay (p < 0.001). Positive resection margins were confirmed in five cases (6.0%) in the non-ICG group, whereas there were none in the ICG group (p = 0.008). Real-time confirmation was possible during laparoscopy, and the injected ICG did not affect the surgical procedure or result in adverse events. ConclusionICG fluorescence imaging is feasible and safe and can potentially be used as a tumor-marking agent for determining the surgical resection line.

Fluorescence-supported lymphography and extended pelvic lymph node dissection in robot-assisted radical prostatectomy: a prospective, randomized trial.

To demonstrate the benefits of fluorescence-supported extended pelvic lymph node dissection (ePLND) compared to regular ePLND in robot-assisted radical prostatectomy. 120 patients with intermediate- or high-risk prostate cancer were prospectively randomized (1:1): in the intervention group, indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups, ePLND was performed including additional dissection of fluorescent lymph nodes (LN) in the ICG group. After drop-out of two patients, 59 patients were allocated to the control (A) and intervention group (B) with a median PSA of 8,6ng/ml. Median console time was 159 (A) vs. 168 (B)min (p = 0.20) with a longer time for ICG-ePLND: 43 (A) vs. 55min (B) (p = 0.001). 2609 LN were found with significantly more LN after ICG-supported ePLND with a median of 25 vs. 17 LN in A (p < 0.001). Nodal metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p = 0.40). In seven of nine patients, ICG-ePLND identified at least one cancer-positive LN (sensitivity 78%), 27 of 62 cancerous LN were fluorescent. Symptomatic lymphocele occurred in one patient in a and in three patients in b (p = 0.62). After a median follow-up of 22.9months, PSA levels were similar. While ICG-ePLND seems to be beneficial for a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity is not sufficient to recommend stand-alone ICG lymph node dissection.

A Novel Indocyanine Green Fluorescence-Guided Video-Assisted Technique for Sentinel Node Biopsy in Breast Cancer.

The equipment to detect indocyanine green (ICG) fluorescence for sentinel lymph node (SLN) biopsy in breast cancer is not widely accessible nor optimal. The fluorescence appears as a poorly defined white shine on a black background, and dimmed lighting is required. The aim of this study was to assess the feasibility, accuracy and healthcare costs of a novel approach for SLN biopsy by a video-assisted ICG-guided technique. The technique for detecting SLN was radioisotope (RI) in 194 cases, video-assisted ICG-guided in 70 cases and a combined method in 71 cases. In the video-assisted ICG group, a full HD laparoscopic system equipped with xenon lamps was used for a laser-free detection of ICG within a colored and magnified high-resolution image. Detection of ICG fluorescence using a laparoscope with a near-infrared filter provided a highly defined and colored image during SLN biopsy. SLN was identified in 100% of patients in all groups. Multiple SLNs were identified in 0.5% of RI patients, in 12.9% of ICG patients and in 14.1% of ICG+RI patients (p<0.0001). In ICG+RI group, 95.1% of lymph nodes were radioactive and 92.7% were fluorescent. Operative times and healthcare costs were equivalent between groups. Video-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLN biopsy, with equivalent efficacy compared to RI, providing an accurate staging of the axilla.

Visualized Evaluation of Blood Flow to the Gastric Conduit and Complications in Esophageal Reconstruction

Evaluation of the blood supply to gastric conduits is critically important to avoid complications after esophagectomy. We began visual evaluation of blood flow using indocyanine green (ICG) fluorescent imaging in July 2015, to reduce reconstructive complications. In this study, we aimed to statistically verify the efficacy of blood flow evaluation using our simplified ICG method. A total of 285 consecutive patients who underwent esophagectomy and gastric conduit reconstruction were reviewed and divided into 2 groups: before and after introduction of ICG evaluation. The entire cohort and 68 patient pairs after propensity score matching (PS-M) were evaluated for clinical outcomes and the effect of visualized evaluation on reducing the risk of complication. The leakage rate in the ICG group was significantly lower than in the non-ICG group for each severity grade, both in the entire cohort (285 subjects) and after PS-M; the rates of other major complications, including recurrent laryngeal nerve palsy and pneumonia, were not different. The duration of postoperative ICU stay was approximately 1 day shorter in the ICG group than in the non-ICG group in the entire cohort, and approximately 2 days shorter after PS-M. Visualized evaluation of blood flow with ICG methods significantly reduced the rate of anastomotic complications of all Clavien-Dindo (CD) grades. Odds ratios for ICG evaluation decreased with CD grade (0.3419 for CD ≥ 1; 0.241 for CD ≥ 2; and 0.2153 for CD ≥ 3). Objective evaluation of blood supply to the reconstructed conduit using ICG fluorescent imaging reduces the risk and degree of anastomotic complication.

Real-Time Fluorescent Sentinel Lymph Node Mapping with Indocyanine Green in Women with Previous Conization Undergoing Laparoscopic Surgery for Early Invasive Cervical Cancer: Comparison with Radiotracer ± Blue Dye

Study ObjectiveTo evaluate the added value of the fluorescence dye indocyanine green (ICG) for sentinel lymph node (SLN) mapping in women with cervical cancer who had undergone previous conization (stage 1A-1B1) by comparing ICG versus Tc99m radiotracer + blue dye (BD). DesignRetrospective study (Canadian Task Force classification II-2). SettingTwo European academic medical centers, San Gerardo Hospital, Italy and University of Berne, Switzerland. PatientsSixty-five women with early stage (IA-IB1) cervical cancer who had undergone previous conization and who underwent SLN mapping with Tc99m ± BD (n = 23) or ICG (n = 42) followed by pelvic lymphadenectomy and fertility-sparing surgery or hysterectomy were included in this analysis. InterventionOverall detection rate and bilateral SLN mapping rates of ICG were compared with those obtained using the standard Tc99m radiocolloid and BD. Measurement and Main ResultsOverall, 220 SLNs were detected. The median number of SLNs per patient in the Tc99m ± BD group was 2 (range, 1–5) and in the ICG group, 3 (range, 2–15). The detection rate of SLNs was 95.7% in Tc99m ± BD group and 100% in the ICG group (p = .354). The women injected with ICG had a higher rate of bilateral mapping of the SLNs as compared with the Tc99m ± BD group (95.2% vs 69.6%, p = .016%). Only 12% of the patients (8/65) presented metastatic nodes, 2 in the Tc99m ± BD group and 6 in the ICG group. ConclusionIn early-stage cervical cancer patients conization had no significant impact on the SLN detection rate using both techniques (ICG and radiotracer ± BD). In this scenario a higher bilateral mapping rate was confirmed using the fluorescent dye ICG rather than the standard techniques.

PD10-01 OUTCOMES OF FLUORESCENCE SUPPORTED LYMPH NODE DISSECTION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY – A PROSPECTIVE RANDOMIZED CLINICAL TRIAL

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2017PD10-01 OUTCOMES OF FLUORESCENCE SUPPORTED LYMPH NODE DISSECTION IN ROBOT-ASSISTED RADICAL PROSTATECTOMY – A PROSPECTIVE RANDOMIZED CLINICAL TRIAL Nina Harke, Christian Wagner, Katarina Urbanova, Michael Godes, Mustapha Addali, Bernhard Fangmeyer, Andreas Schuette, and Jorn H. Witt Nina HarkeNina Harke More articles by this author , Christian WagnerChristian Wagner More articles by this author , Katarina UrbanovaKatarina Urbanova More articles by this author , Michael GodesMichael Godes More articles by this author , Mustapha AddaliMustapha Addali More articles by this author , Bernhard FangmeyerBernhard Fangmeyer More articles by this author , Andreas SchuetteAndreas Schuette More articles by this author , and Jorn H. WittJorn H. Witt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.564AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The detection of lymph node metastases has a major impact on patients with prostate cancer. However, there is still a debate on the extent of pelvic lymphadenectomy, the usage of near-infrared fluorescence (NIRF) and sentinel node dissection in radical prostatectomy. This study aims to demonstrate the outcomes of NIRF lymph node dissection in robot-assisted radical prostatectomy. METHODS 120 patients with intermediate (72%) or high risk (28%) prostate cancer were prospectively randomized (1:1): in the intervention group indocyanine green (ICG) was injected transrectally into the prostate before docking of the robot. In both groups an extended pelvic lymph node dissection (ePLND) was performed including eventual dissection of fluorescent lymph nodes (LN) in the ICG group. RESULTS After exclusion of two drop-outs, 59 patients were allocated in the control (A) and intervention group (B) with a median PSA of 8,6 ng/ml. Median console time was 159 (A) vs. 168 (B) minutes (p=0,20) with a longer time for NIRF ePLND: 43 (A) vs. 55 minutes (B) (p=0,001). Overall, 2609 LN (median 22 LN) were found. In the ICG group 582 fluorescent LN were identified, while 899 were non-fluorescent. Significantly more LN could be harvested in B with median 25 LN vs. 17 in A (p<0,001). In 6 of the 59 patients in the intervention group, 19 additional fluorescent LN were found outside of the routine ePLND field. 15 out of 118 patients presented 87 nodal metastases. These metastases were detected in 6 patients in A (25 cancerous LN) vs. 9 patients in B (62 positive LN) (p=0,40). In 7 of 9 patients, NIRF ePLND identified at least one cancer-positive LN (sensitivity 78%), although 35 of 62 cancerous LN were non-fluorescent. No adverse reactions to ICG, no significant differences in complication rates (p=0,15); lymphocele occurred in one patient in A and in three patients in B (p=0,62). After six months, 5,8% vs. 3,7% showed a PSA>0,2 ng/ml (p=0,37) with a median PSA of 0,01 ng/ml in both groups (p=0,96). There was no difference in adjuvant therapy with 10 patients undergoing radiation therapy, 7 patients with androgen deprivation therapy (ADT) and 3 patients with combined radiation and ADT (p=0,78). CONCLUSIONS Without increased risk for the patient, NIRF ePLND leads to a significantly higher yield of lymph nodes. While it therefore seems to be beneficial with regard to a better understanding of the lymphatic drainage and a more meticulous diagnostic approach, the sensitivity seems not to be sufficient to recommend stand-alone NIRF sentinel lymph node dissection. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e199 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Nina Harke More articles by this author Christian Wagner More articles by this author Katarina Urbanova More articles by this author Michael Godes More articles by this author Mustapha Addali More articles by this author Bernhard Fangmeyer More articles by this author Andreas Schuette More articles by this author Jorn H. Witt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical efficacy of navigation of sentinel lymph node combined with endoscopic submucosal dissection in laparoscopic surgery for non curative treatment of early gastric cancer

Objective To explore the clinical efficacy of navigation of sentinel lymph node(SLN) combined with endoscopic submucosal dissection(ESD) for non curative treatment of early gastric cancer. Methods Clinical data of 9 cases with early gastric cancer treated with ESD from August 2015 to December 2015 were enrolled. The SLNs were explored by laparoscopy after nano carbon or indocyanine green(ICG)was injected under endoscopy. Then all stained nodes were resected by laparoscopy. Results The mean number of SLN were 2.75±1.50 in ICG group, which was significantly smaller than the number in nano carbon group(8.40±4.93)according to the laparoscopic pathology, so the accuracy of ICG was higher than that of nano carbon. But ICG performed better in development. The postoperative complications such as postoperative intestinal obstruction, enteritis and gastric paralysis were found in 5 patients of nano carbon group. But no serious complications after operation were found in patients of ICG group. Conclusion Application of ICG can help avoid the excessive removal of tissue, and reduce the incidence of complications. ICG, as a new type of tracer for early gastric cancer, shows good application prospects. Key words: Sentinel lymph node biopsy; Early gastric cancer; Nano carbon; Indocyanine green

Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy.

It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy. All consecutive patients (N=22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805nm; filter: 825nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes. ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203±89 (125-331) and 207±112 (130-356)s, respectively. The mean (range) fluorescence duration in these glands was 20.8±6.0 (16.6-35.8) and 20.1±7.3 (15.5-33.8)min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P=0.048). ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.

Sentinel lymph node mapping in patients with stage I endometrial carcinoma: a focus on bilateral mapping identification by comparing radiotracer Tc99m with blue dye versus indocyanine green fluorescent dye.

The aim of this study was to compare technetium radiocolloid (Tc99m)+blue dye (BD) versus Indocyanine green (ICG) fluorescent dye in terms of the overall detection rate and bilateral sentinel lymph node (SLN) mapping in patients with endometrial carcinoma. Patients from five European centers with apparently confined clinical stage I endometrial cancer were reviewed. A comparison was made between women who received SLN mapping with pelvic and/or aortic lymphadenectomy (LND), and women who underwent SLN algorithm (SA), was also performed between the two groups. Three hundred and forty-two (342) women were involved (147 in the Tc99m+BD group and 195 in the ICG group). The overall detection rate of SLN biopsy was 97.3% (143/147) for women in the Tc99m+BD group and 96.9% (189/195) for women in the ICG group (p=0.547). The bilateral mapping rate for ICG was 84.1%-significantly higher with respect to the 73.5% obtained with Tc99m+BD (p=0.007). No differences in overall sensitivity (OS) and overall false negative rate (FNR) were seen between LND and SA (p value=0.311), whereas the negative predictive value (NPV) was in favor of SA group (p value=0.030). In this study, fluorescent mapping using ICG resulted equivalent to the standard combined radiocolloid and BD, but real-time SLN mapping achieves a higher bilateral detection rate. The added value that this fast emerging technology promises to give certainly warrants future studies to further consolidate the advantages there are over the standard technique.

Effect of photodynamic therapy with two photosensitizers on Streptococcus mutants: In vitro study

Background and objectivesStreptococcus mutans (S. mutans) colonizes the oral cavity and causes dental caries and periodontal diseases. Considering the importance of the treatments that decrease pathogenic microorganisms, the aim of the present research was the assessment of the antimicrobial effect of Photodynamic Therapy (PDT) with Methylene Blue (MB) and Indocyanine Green (IG) photosensitizers on S. mutans. Materials and methodsIn this In vitro experimental study, Sixty four caries-free first premolars were contaminated with 0.5 McFarland S.mutans suspension and were randomly assigned to 4 groups. The teeth in the first group were impregnated with 2% MB while the teeth in the second group were impregnated with 0.2% IG. The teeth in the first group were irradiated with continuous-wave 660nm dod laser with 40mw output power, energy density of 2.4J/cm2 and 100% duty cycle for 60s, while the teeth in the second group were irradiated with continuous -wave 810nm diode laser with 100mw out power, density energy of 6J/cm2 and 100% duty cycle for 60s in contact mode. In the third group, the teeth were suspended in 0.2% Chlorhexidine for 30s. The fourth group was considered as the control. The teeth were sampled before and after the interventions and the samples were incubated in Blood Agar for 24h. Afterwards, the number of S. mutans colonies were counted. Data were statistically analyzed by Kruskal-Wallis, Dunn's and Friedman tests. ResultsIn the groups treated with a combination of MB and IG and laser irradiation and also in the Chlorhexidine group, the final number of S. mutans colonies equaled zero. In “MB and IG groups without laser irradiation”, although the amount of microorganisms decreased, but the number of colonies did not reach zero. Pair comparisons by Dunn's test showed that there was a significant difference between “MB and IG groups without laser irradiation” and the other experimental groups p=0.03). ConclusionPDT with MB and IG photosensitizers and also Chlorhexidine mouthwash, have the ability to completely eradicate S. mutans bacterial colonies.

A prospective randomized trial comparing colorimetric and fluorescent imaging for pelvic sentinel lymph node mapping in endometrial cancer

Objectives: To prospectively compare sentinel lymph node (SLN) mapping using isosulfan blue (ISB) with indocyanine green (ICG) using near-infrared imaging in patients with apparent uterine-confined endometrial cancer (EC). Our aims were to: (1) test the null hypothesis of no difference between ISB detection of SLN versus ISB + ICG in a randomized clinical trial, and (2) determine sensitivity and negative predictive value for detection of lymph node (LN) metastasis. Methods: Following US Food and Drug Administration and institutional review board approvals, 200 endometrial cancer patients were enrolled (September 2012 to January 2015) with 5 surgeons. Patients were randomized using SAS version 9.2, with 10% cases allocated to ISB alone. ISB (2 mL) and ICG (2 mL; 1 mg/mL) were injected into the cervix, 2 to 5 mm below the mucosa. All patients underwent robotic-assisted hysterectomy with pelvic ± aortic lymphadenectomy. Retroperitoneal spaces were opened and ISB results recorded on all 200 cases. Envelopes were opened and near-infrared imaging was used per randomization cards on 180 subjects. Results: A total of 180 cases were mapped with ISB + ICG (group A), and 20 cases were randomized to ISB alone (group B). Mean age was 64.5 ± 8.4 years and body mass index was 33 ± 8 kg/m2. Histologies included endometrioid G1 (43%), G2 (30%), G3 (7%), and type II (20%). Pathology characteristics included lymphovascular space invasion (31.5%), DOI more than 50% (27.5%), lesion size greater than 2 cm (77%). Mean time from dye injection to opening of spaces was 10.3 ± 6 minutes and time to complete mapping with LN removal was 22.4 ± 9.4 minutes. Operating room time was 136 ± 36 minutes, total LN were 23.1 ± 10.7. Group A ISB detection of SLN was not different from that of control group B (P = .35). SLN detection for ISB + ICG group A (n = 180) versus all ISB (n = 200) were as follows: bilateral—83.9% versus 40%; unilateral—12.2% versus 36%; and none—3.9% versus 24%, P < .001). Median SLN per case in group A was 2 (range, 0–4). Positive SLNs were found in 39 group A (21.7%) and 2 group B cases (10%). There was 1 false-negative SLN (97.5% sensitivity, 99.3% negative predictive value, 2.5% false-negative rate). SLN was the only positive LN in 25 (62.5%) of 40 node-positive cases. Isolated tumor cells were found in 11 (28.2%) of 39 SLNs compared with 2 (14.3%) of 14 non-SLN metastases. ISB improved the ICG detection of SLNs (3 bilateral, 10 unilateral, 1 LN metastasis). No allergic reactions to either dye were seen. Conclusions: ISB + ICG and near-infrared imaging detected more SLN and LN metastases than ISB alone in this phase III trial. SLN mapping with ICG +ISB had excellent sensitivity for detection of metastasis.