Mg Of Indocyanine Green Research Articles

Pure Laparoscopic Living Donor Right Hepatectomy Using Real-Time Indocyanine Green Fluorescence Imaging

IntroductionIn recent decades, the quantitative and technological development of laparoscopic liver resection has resulted in an extension into the transplantation area.1,2 However, laparoscopic living donor hepatectomy is still in its infancy due to technical difficulties and extreme caution regarding donor safety.3 Several experienced major centers have demonstrated the feasibility and safety of laparoscopic living donor hepatectomy, and recent advances in laparoscopic imaging technology support this move.4 In particular, indocyanine green near-infrared fluorescence imaging helps determine the correct liver parenchyma anatomical resection and the exact point of bile duct division.4-6 This video demonstrates the technique of pure laparoscopic living donor right hepatectomy and the usefulness of indocyanine green fluorescence imaging. MethodsThe donor was a 32-year-old gentleman who decided to donate part of his liver to his wife who was suffering from viral liver cirrhosis and hepatocellular carcinoma. His BMI was 20.3 kg/m2 and the preoperatively estimated donor’s right liver volume was 836 ml, representing 63.6% of his entire liver. With the recipient’s weight of 57 kg, the graft-to-recipient weight ratio (GRWR) was 1.6%. The liver had classic hilar anatomy except that the right posterior intrahepatic duct was joined separately to the left main hepatic duct. The patient setting and the placement of the trocars were the same as for our conventional laparoscopic right hepatectomy technique.7 After right hepatic artery and portal vein isolation and clamping, 2.5 mg of indocyanine green was injected intravenously. ResultsTotal operation time was 370 min and estimated blood loss was 150 ml without transfusion. Indocyanine green fluorescence imaging clearly demonstrated the anatomical demarcation between the lobes and visualized the running of the biliary tree. His postoperative course was uneventful, and he was discharged on postoperative day 7. ConclusionReal-time indocyanine green fluorescence imaging may be particularly helpful for delineating the anatomical surgical plane and determining the appropriate division point of the hepatic duct during laparoscopic living donor hepatectomy.

Efficacy of Assessing Intraoperative Bowel Perfusion with Near-Infrared Camera in Laparoscopic Gastric Cancer Surgery.

Anastomotic leakage is a severe complication after gastric cancer surgery. Inadequate blood supply is regarded as an important risk factor. The aim of the study was to evaluate the feasibility and usefulness of intraoperative assessment of anastomotic vascular perfusion in gastric cancer surgery using near-infrared (NIR) camera imaging with indocyanine green (ICG)-enhanced fluorescence technique. From March 2015 to 2016, 30 patients undergoing laparoscopic gastrectomy for gastric cancer were prospectively evaluated. After completing the anastomosis, 2.5-5.0 mg of ICG was injected via peripheral veins. All anastomoses and resection margins were investigated using NIR camera to assess anastomotic perfusion. The assessment was performed using the adopted perfusion score of fluorescence activity, which ranged from 1 to 5 (1 = no uptake, and 5 = iso-fluorescent to all other segments). Twenty-six distal gastrectomy (20 gastroduodenostomies, 6 gastrojejunostomies), 3 total gastrectomies (TG), and 1 pylorus-preserving gastrectomy were performed. The gap of visualization was 4.1 ± 3.2 minutes (range, 2-15) after ICG injection. Twenty-three of 30 patients (76.7%) showed technically successful ICG visualization. Among gastroduodenostomies, the average scores for gastric and duodenal sides were 3.5 and 3.7. Among gastrojejunostomies, the average scores for gastric, jejunal, and duodenal stump sides were 3.5, 4.0, and 3.8 (jejunojejunostomy, 3.5). Among TG, the average scores for esophagojejunostomy, duodenal stump, and jejunojejunostomy were 3.7, 4.0, 4.0, and 4.7. One case of leakage occurred in this study. Other complications included fluid collection and stenosis in 1 patient each. This study showed intraoperative ICG angiography using NIR camera is feasible and provides imaging of anastomotic blood flow. Further studies are needed for practice.

Identification of plaque location using intraoperative indocyanine green during carotid endarterectomy for patient with near occlusion.

Microscope-integrated near-infrared indocyanine green (ICG) videoangiography (VA) is an effective method of intraoperative blood-flow assessment and identification of plaque location during carotid endarterectomy (CEA). However, the validity of ICG-VA during CEA for patient with near occlusion has not been elucidated. Thirty-four CEA procedures were performed between June 2009 and December 2017 for patient with near occlusion, which are more than 95% stenosis. The lesions were classified into three groups according to the diameter of distal ICA compared with ipsilateral external carotid artery (ECA), as normal diameter (>100%), moderate diameter reduction (50-100%), severe diameter reduction (<50%). Five mg of ICG was injected intravenously before arteriotomy, and ICG-VA was taken to identify the distal end of the plaque. Depiction of the distal end and its accuracy were retrospectively reviewed. There were 18 cases with normal diameter group, 14 cases with moderate diameter reduction group, and 2 cases with severe diameter reduction group. All but one case in the severe diameter reduction group showed apparent distal end signal which were confirmed by arteriotomy afterward. The present study clearly denotes that ICG-VA can visualize the carotid plaque distal end during the CEA, even with the patient with near occlusion. However, it should be noted that there may be a difficulty in visualization of the distal plaque end for patient with severely collapsed distal ICA.

The role of indocyanine green (ICG) in robotic liver surgery

Introduction: The ability of ICG to provide a fluorescence appearance under infrared light enables its wide usage in surgical oncology. It is capable of identifying hepatic lesions intraoperatively and identifies anatomic sections in real time. The purpose of this study is to describe the technical aspects of its use and to evaluate the diagnostic value of ICG fluorescence in robotic liver surgery in a single-center. Methods: Patients who underwent robotic liver resection at Changi General Hospital for primary liver cancer and colorectal liver metastases (CLM) were included. All cases were completed robotically with daVinciXi. For identification of liver tumor, 5mg of ICG was given intravenously 1-3 days prior to surgery. For identification of anatomical segments, negative staining method was used by giving 5mg of intravenous ICG after clamping of the segmental inflow. Firefly fluorescence imaging was used for illumination. Results: A total of 9tumors were resected in 8patients. Of the 9 tumors, ICG was used for tumor identification in 4 and negative staining for anatomical resection in 6. All 4 tumors were successfully identified with ICG fluorescence. The anatomical resection performed were right posterior sectionectomy (n=4), right anterior sectionectomy (n=1), and right hepatectomy (n=1). Negative staining was clearly identified in 4 patients; however it was not demonstrated in two patients due to failure to tightly control the hepatic inflow. Conclusion: Robotic ICG fluorescence can provide clear identification of tumors on liver surface. Tight control of the inflow is crucial to obtain a successful real time negative staining for anatomical resection.

PS02.069: CERVICAL GASTROPLASTY ANASTOMOSIS AFTER ESOPHAGECTOMY: INDOCYANINE GREEN FLUORESCENCE IMAGING EVALUATION AND TECHNICAL SURGICAL ASPECTS

Abstract Description One of the most frequent complication after esophagectomy is the anastomotic leakage, which is a determiming factor of morbidity and mortality after surgical treatment. The best location for the esophagogastric anastomosis (cervical or intra-thoracic) has been topic of discussion for many years, and surgical aspects as resected margins, recurrent nerve trauma and mainly the vascularization of the anastomosis. In this video we performed a cervical gastroplasty anastomosis (McKeown), side-to-side, stapled (linear stapler) with a thin gastric tube conduit, and after that we aimed to determine the feasibility and usefulness of indocyanine green (ICG) fluorescence imaging to evaluate the gastric conduit perfusion during an esophagectomy. After pulling up the gastric conduit trhought the mediastinum and after performing the cervical anastomosis, 5 mg of ICG was in jected as a bolus and visual assessment of the blood supply of the gastric conduit was seen. This patient was a 63 years old, male, with adenocarcinoma of esophago-gastric junction (Siewert II) underwent to neoadjuvant quimiotherapy (FOLFOX regimen) and submitted after 3 cycles to esophagectomy (thoracoscopy and laparoscopy). No fistula was found in post operative follow-up, and either complications. Disclosure All authors have declared no conflicts of interest.

PS02.076: VISUALIZATION OF BLOOD SUPPLY ROUTE TO THE RECONSTRUCTED STOMACH BY INDOCYANINE GREEN FLUORESCENCE IMAGING DURING ESOPHAGECTOMY, 2ND REPORT

Abstract Background Recently, indocyanine green (ICG) fluorescence imaging has been used to visualize the blood supply when anastomosis is performed in vascular surgery. We have reported the three blood supply routes to the reconstructed stomach using ICG fluorescence imaging for reconstruction during esophagectomy. Blood flow routes in the 33 patients with esophageal cancer were classified into categories on the basis of ICG imaging findings: the gastric wall route, the greater curvature route, and the omentum and splenic hiatal route. The gastric wall route was found in 13 patients and characterized by large blood vessels in the gastric wall. The greater curvature route was present in 11 patients and characterized by blood vessels in the greater omentum. The omentum and beside splenic hilum route was found in 22 patients. Blood vessels ran in the greater omentum beside the splenic hilum. a photodynamic eye (PDE) showed blood flow from right gastroepiploic artery, omentum vessels, left gastroepiploic artery, splenic hiatal vessels, short gastric artery, and gastric wall vessels to the top of the reconstructed stomach. The ‘splenic hiatal route’ was present in 66.7% of the patients and was formed by large vessels or networks of small vessels. We rechecked the ‘splenic hiatal route’ cases and recognize that the branch parted from the right gastroepiploic artery. We tried preservation of the ‘splenic hiatal route’. Methods Since January 2017, we have preserved the ‘splenic hiatal route’ and performed ICG fluorescence imaging in 5 patients with thoracic esophageal cancer who underwent thoracic esophagectomy. After pulling up the reconstructed stomach, 2.5 mg of ICG was injected as a bolus. ICG fluorescence imaging was performed with a near-infrared camera, and the images were recorded. Results ICG fluorescence was easily detected in all patients 1 min after injection. Vascular networks were well visualized in the gastric wall and omentum. The blood supply route was visualized the ‘splenic hiatal route’ in all patients. Conclusion On ICG fluorescence imaging, the splenic hiatal vessels would be the major blood supply for the anastomosis in most patients. Disclosure All authors have declared no conflicts of interest.

Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy.

Injury to the thoracic duct (TD) is the most common complication after a left lateral neck dissection, and it carries a high degree of morbidity. Currently, no routine diagnostic imaging is used to assist with TD identification intraoperatively. This report describes the first clinical experience with lymphangiography using indocyanine green (ICG) during lateral neck dissections. In six patients undergoing left lateral neck dissection (levels 2-4) for either thyroid cancer or melanoma, 2.5-5mg of ICG was injected in the dorsum of the left foot 15min before imaging. Intraoperative imaging was performed with a hand-held near infrared (NIR) camera (Hamamatsu, PDE-Neo, Hamamatsu City, Japan). In five patients, the TD was visualized using NIR fluorescence, with a time of 15-90min from injection to identification. Imaging was optimized by positioning the camera at the angle of the mandible and pointing into the space below the clavicle. No adverse reactions from the ICG injection occurred, and the time required for imaging was 5-10min. No intraoperative TD injury was identified, and no chyle leak occurred postoperatively. For the one patient in whom the TD was not identified, it is unclear whether this was related to the timing of the injection or to duct obliteration from a prior dissection. This is the first described application of ICG lymphangiography to identify the thoracic duct during left lateral neck dissection. Identification of TD with ICG is technically feasible, simple to perform with NIR imaging, and safe, making it a potential important adjunct for the surgeon.

Real time indocyanin green near infrared lymphangiography for the reduction of drainage volume after neck dissection

BackgroundTo investigate the role of indocyanine green (ICG) lymphangiography in the reduction of drainage after neck dissection. MethodsPatients with oral cavity squamous cell carcinoma were randomized into Group A (study group) and Group B (control). In the study group, upon the completion of neck dissection, a total of 2.5 mg of ICG was injected submucosally at the four quadrants around the tumour. Another 2.5 mg of ICG was injected subdermally in the groin bilaterally. The neck was screened using Near Infrared fluorescence. The presence of lymphatic leakage was noted and plicated with silk stitches. The total drainage volume of post-operative day 1, day 2 and the total accumulated volume until drain removal was measured. ResultsTwenty-two patients (Group A, n = 12; Group B, n = 10) were recruited. All patients in Group A had at least one site of lymphatic leakage identified. One patient in Group B developed chylous fistula and was excluded from analysis. The mean total drain output for day 1 and 2 after surgery, as well as the mean total output before drain removal, were significantly lower in Group A (22.4 ml vs. 86.2 ml [p = .02]; 14.2 ml vs. 72.8 ml [p = .02]; and 58.4 ml vs. 392 ml [p = .01], respectively), allowing earlier drain removal (2.2 days vs. 7.2 days, p = .02). ConclusionsIntra-operative ICG lymphangiography is useful in the reduction of drainage volume after neck dissection for caners in the head and neck region.

Laser Angiography to Assess the Vaginal Cuff During Robotic Hysterectomy.

Background and Objectives:Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH.Methods:This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion.Results:Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175).Conclusion:Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.

P18.01 Indocyanine green fluorescence endoscope: the useful points in endonasal transsphenoidal surgery

AbstractIntroduction:For the safe operation, exact orientation during endoscopic endonasal transsphenoidal surgery (ETSS) is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MRI images. On Doppler sonographs the shape of concealed arteries and veins cannot be visualized. To solve these problems we evaluated the clinical usefulness of the indocyanine green (ICG) endoscope.Materials and Methods:We enrolled 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), and chordomas (n = 2); there was one patient each with Rathke’s cleft cyst, a dermoid cyst, and fibrous dysplasia. After opening the sphenoid sinus and placing the ICG endoscope, we injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary. Intraoperative real-time measurement of ICG signals was performed in 4 of microadenomas.Results:The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The cavernous sinus and the attachment of tuberculum sellae meningiomas were identified through the dura matter. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time. Elevation of ICG signals was relatively delayed in microadenoma compared to the area of normal pituitary.Conclusions:In ETSS, the real time and high resolution image of ICA and cavernous sinus with the ICG endoscope is strongly useful. We suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function, and different elevation pattern of ICG signal between microadenoma and normal pituitary helps to identify margin of them.

Lymphatic Clearance in the Hand/Forearm of Healthy Controls and Human Hand Transplant Recipients Using Infrared Imaging of Indocyanine Green

Objective: Abnormal lymphatic function defined by scintigraphy in hand transplant patients has been reported. In cases of chronic edema, it is not clear whether swelling is due to inadequate lymphatic function, vascular leakage, or both. In hand transplantation, deep lymphatic vessels are not anastomosed. Surface lymphatic drainage reestablishes spontaneously. Feasibility of upper limb lymphatic infrared imaging with indocyanine green (ICG) has been demonstrated in breast cancer patients. However, there is no body of information on objective measurement of lymphatic function with ICG using normal controls. During pilot scans of our transplant recipients, it became clear that we had to define normal subcutaneous ICG clearance before we could define abnormal function. The aim of this study is to establish parameters of lymphatic function defined by clearance of subcutaneous injection of ICG in normal controls. The ultimate goal is to noninvasively define adequate and inadequate lymphatic function in hand transplant and replant patients. Methods: After obtaining institutional review board approval (IRB) approval, we enrolled 10 (age range, 23-54; 5 males and 5 females) normal controls. Patients with a history of allergy to iodine or shellfish were excluded. Hand transplant recipients were imaged initially using a dose of 0.25 mg of ICG. Subsequently, dose titration studies were performed in normal controls. Doses ranged from 0.25 mg to 0.025 µg of dye per subcutaneous injection site on the volar or dorsal side of the hand in 100 µL of saline. The stock vial of ICG is reconstituted with sterile water per manufacturer’s (Novodaq, Novadaq Technologies Inc, Ontario, Canada) instructions. Subject hand and upper extremity was then imaged using the LUNA Florescence Angiography unit at 15 minutes to hourly intervals up to 6 hours postinjection. Selected patients were also imaged every 24 hours until dye cleared completely from the injection site. Images were analyzed using SPYi software. Results: Injection of 2 sites on the dorsal, but not volar side of the hand, allows clear visualization of drainage of ICG by both ulnar and radial lymphatic vessels from the hand to the antecubital fossa and the arm in the brachial veins. Relatively low doses of dye allow excellent visualization. In normal controls, ICG can be visualized in the antecubital fossa in a linear pattern by 15 minutes and in significant amounts by 30 minutes. Higher doses of dye were associated with excessive retention of dye at injection site with no improvement in vessel visualization. Hand transplant recipients demonstrated a mixture of linear and radial drainage, with more involvement of small superficial capillary-like networks. Conclusions: These pilot studies show that subcutaneous clearance of ICG as a targeted near-infrared (NIR) molecular imaging agent can be used to define lymphatic function. By combining subcutaneous injection with intravenous imaging of ICG, we hypothesize that the role of lymphatic function versus vessel leakage in chronic edema can be differentiated. Further studies are needed to identify whether this could be helpful in the evaluation/treatment of patients with lymphostasis related to burns, cellulitis, other infections, and compartment syndrome.

Laparoscopic Fluorescence to Detect and Treat Subcapsular “Very Small” Hepatocellular Carcinoma in Patients on Waiting List for Liver Transplantation

Introduction: Last year M. Sakoda and H. Kudo described intraoperative fluorescence imaging techniques using indocyanine green (ICG) and surgeons began to use them clinically to delineate cancers in the liver during laparoscopic procedures (hepatectomy and/or ablation). Intraoperatively, cancers in the liver can be identified through visualization of ICG, which remains only in the hepatocellular carcinoma (HCC) tissues. Transplantation is the best option for patients with advanced cirrhosis and HCC; however, there is an increasing organ shortage. Therefore, a strong recipient selection for HCC criteria is mandatory. Moreover, the laparoscopic ablation could obtain a strong tumor downstaging. ICG fluorescence imaging is easy to perform and facilitates identification of subcapsular HCC during laparoscopic procedures. Methods: A 60-year-old w/c male was admitted for HCC and alcoholic cirrhosis (Child A6, MELD 12). The medical history showed the following: diabetes not insulin dependent, hypertension, ischemic cardiomyopathy, aortic insufficiency, and esophageal varices stage II. The liver function tests were within the normal limits. The alpha-fetoprotein level was 1.9 ng/mL (NV: <4 ng/mL). Patient was on waiting list for liver transplantation. We injected intravenously a bolus of 3 mg of ICG (Infracyanine® 25 mg/10 mL; SERB™, Paris, France) 12 hours before surgery. During this video, we show a laparoscopic exploration of a cirrhotic liver by fluorescence that confirmed the presence of three suspected nodules, viewed at MRI, plus another 3 mm nodule not detected on intraoperative ultrasound. Results: During the wedge resection of the segment IVa nodule, the fluorescence guided us to achieve a good resection margin. Furthermore, during the ablation of the others two suspected nodules, we noticed that during the ablation, the intensity of the fluorescence of the nodules decreased progressively till it disappeared completely. Imaging at the 3-month follow-up showed no cancer recurrence. The histology of the resected sample and the biopsied nodules confirmed HCC. Conclusion: In conclusion, the laparoscopic fluorescence may have a great sensitivity to detect subcapsular “very small” (<5 mm) HCC, facilitating the liver resection comparing to the only intraoperative ultrasound. The ICG may improve the selection of the patients on waiting list for liver transplantation due to HCC. In fact, patients beyond the Milan criteria will be removed from the transplant list. Furthermore, the fluorescence may be a good marker to know if the ablation procedure is completed or not. Its application can be used also in the setting of liver resection and ablation procedures outside liver transplantation. No competing financial interests exist. Runtime of video: 7 mins

Abstract P3-01-03: Optimal concentration of indocyanine green in near-infrared fluorescence guided sentinel lymph node biopsy in breast cancer

Abstract Background: Near-infrared (NIR) fluorescence-guided sentinel lymph node biopsy (SLNB) using indocyanine green (ICG) has been successfully applied in various kinds of cancers, especially in breast cancer. Optimizing the concentration of ICG without using human serum albumin in natural lymphatic system is still required. Methods: 25mg of ICG was diluted with distilled water (DW) or normal saline (NS). Dilution concentrations used for measurement were 0.25μg/mL, 0.5μg/mL, 2.5μg/mL, 5.0μg/mL, 25μg/mL, and 250μg/mL. The brightness of fluorescence was measured by an image system called Visual Navigator (SH System, Korea). We used graphic software (GIMP, version 2.8.14, The GIMP Team) to measure the brightness. We assumed that drained serous lymphatics from a breast cancer patient can reflect a natural lymphatic condition injected with ICG in the operation field. Drained lymphatics were mixed to reduce the concentration of ICG by half that was diluted with DW or NS. We also measured the brightness of fluorescence diluted with DW or NS that was mixed with drained lymphatics. After this screening test, we subdivided the range which brightness was measured as 100 and adjusted the intensity of illumination for more specific results. Results: Highest brightness values were measured as 100 between 2.5μg/mL and 25μg/mL concentration of ICG with DW dilution in screening settings, and the values of brightness were measured as 100 between 2.5μg/mL and 5.0μg/mL concentration of ICG with NS dilution. When drained lymphatics were mixed together, the values of brightness were measured as 100 between 2.5μg/mL and 25μg/mL concentration of ICG with DW or NS dilution. After subdividing the ICG concentration to 2.5μg/mL, 3.13μg/mL, 5.0μg/mL, 6.25μg/mL, 12.5μg/mL and 25μg/mL with adjusting the intensity of illumination, the highest brightness value was measured as 76 in 5.0μg/mL concentration of ICG with DW dilution. When diluting with NS, the highest brightness value was measured as 61 in 5.0μg/mL ICG concentration. After mixing with drained lymphatics, the highest brightness value was both 79 in 5.0μg/mL concentration of ICG with DW and NS dilution. Conclusions: This study showed a practically optimal ICG concentration range in fluorescence guided SLNB. The optimal range of ICG concentration is from 3.13μg/mL to 6.25μg/mL with DW or NS dilution. Although 5.0μg/mL met the best result, adjustment for individual settings may be considered. Citation Format: Paik H-J, Yi HW, Park S, Ryu JM, Nam SJ, Lee JE, Kil WH, Lee SK, Bae SY, Kim SW. Optimal concentration of indocyanine green in near-infrared fluorescence guided sentinel lymph node biopsy in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-03.

Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with indocyanine-green (ICG).

Background and ObjectivesTo evaluate feasibility of intraoperative visualization of embryologically defined organ compartments and their drainage by ICG in uterine cancer.MethodsTotal of 2.5 mg of ICG have been injected into cervix or corpus in uterine cancer patients immediately prior to surgery. Green fluorescence was intermittently detected during robotically assisted laparoscopic surgery (Firefly System®, Intuitve Surgical Inc.). Total of 36 patients with uterine cancer without macroscopically suspicious nodes were evaluated with respect to their compartmental lymphatic network, collecting lymphatic vessels, and the connection to the postponed lymph basins.ResultsMüllerian (sub) compartment and transport of lymph fluid along the lymphatic collectors and connecting vessels to the postponed lymph basins could be visualized invariably in all patients. Cervix drained along the ligamentous and caudal part of vascular mesometria, whereas midcorporal and fundal drainage occurred along the upper part of vascular mesometria and along the mesonephric pathway along the ovarian vessels.ConclusionsVisualization of lymphatic network and downstream flow of lymphatic fluid to the postponed lymph basins by ICG is feasible; it can be used to navigate along compartment boarders for education, intraoperative orientation, and quality control. It seems to confirm the compartmental order of pelvic organ systems and postponed lymph basins. J. Surg. Oncol. 2016;113:554–559. © 2016 Wiley Periodicals, Inc.

Effect of indocyanine green dye administration on cerebral oxygen saturation.

Sir, Near-infrared spectroscopy (NIRS) is a non-invasive continuous method of measuring regional cerebral oxygen tissue saturation (SctO2).[1] It uses a technique similar to pulse oximetry where light absorption in wavelength 600–900 nm is used. Indocyanine green (ICG) is a water soluble and iodide containing dye that fluoresces when exposed to infrared light. This property of ICG is used for the intra-operative assessment of blood flow during aneurysm surgery. Safety of ICG usage in clinical settings has been demonstrated for determining cardiac output, hepatic function and liver blood flow and for ophthalmic angiography.[2] There have been hypotension, urticarial reaction or anaphylaxis and falsely low pulse oximetry recording during or following use of ICG.[3,4] Contrary to falsely low pulse oximetry recordings, ICG administration has been shown to increase SctO2.[4] Here, we are describing the effect of ICG administration on SctO2. A 65-year-old male patient was scheduled to undergo clipping of right supraclinoid internal carotid artery aneurysm under general anaesthesia. Apart from the routine monitoring, we placed bilateral NIRS sensors over the forehead of the patient. After administration of 10 mg of ICG, the SctO2 on both the sides suddenly increased to 100 from a baseline of about 65–75% and gradually decreased to the baseline value after about 15 min [Figure 1]. There were no associated haemodynamic changes. Figure 1 Snap shot of near infrared spectroscopy monitor showing the graphical trend of the cerebral oxygen saturation. Furthermore, clearly seen is the sudden acute increase in saturation after injection of indocyanine green at two different time points and gradual ... This sudden increase in SctO2 following administration of ICG can be explained by the principle applied in NIRS sensors. NIRS uses wavelengths between 700 and 850 nm to determine regional cerebral oxygen SctO2 by differentiating oxyhaemoglobin from reduced haemoglobin in the frontal lobe. Thus, any substances that absorb infrared light of the same wavelength produced by the light-emitting diodes may affect the absorption of light as they traverse the blood and tissues.[5] ICG has a characteristic absorption peak at around 805 nm and this is likely to reduce the amount of detected light in the 810 nm wavelength of the NIRS device, which would be interpreted as an increased oxyhaemoglobin concentration leading to falsely elevated SctO2 reading.[6] The effect of this falsely elevated SctO2 on the clinical outcome of the patients is not known. Despite these changes, the remaining of the surgical procedure was uneventful or did the patient develop any new neurological deficits and patient's trachea was successfully extubated at the end of the procedure. The anaesthesiologists and neurosurgeons must be aware of this interaction of ICG and cerebral oxygen SctO2 in the intra-operative period. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Usefulness of the indocyanine green fluorescence endoscope in endonasal transsphenoidal surgery.

To avoid disorientation during endoscopic endonasal transsphenoidal surgery (ETSS), the confirmation of anatomical landmarks is essential. Neuronavigation systems can be pointed at exact sites, but their spatial resolution power is too low for the detection of vessels that cannot be seen on MR images. On Doppler ultrasonography the shape of concealed arteries and veins cannot be visualized. To address these problems, the authors evaluated the clinical usefulness of the indocyanine green (ICG) endoscope. The authors included 38 patients with pituitary adenomas (n = 26), tuberculum sellae meningiomas (n = 4), craniopharyngiomas (n = 3), chordomas (n = 2), Rathke's cleft cyst (n = 1), dermoid cyst (n = 1), or fibrous dysplasia (n = 1). After opening the sphenoid sinus and placing the ICG endoscope, the authors injected 12.5 mg of ICG into a peripheral vein as a bolus and observed the internal carotid arteries (ICAs), cavernous sinus, intercavernous sinus, and pituitary. The ICA was clearly identified by a strong fluorescence signal through the dura mater and the covering thin bone. The intercavernous and cavernous sinuses were visualized a few seconds later. In patients with tuberculum sellae meningiomas, the abnormal tumor arteries in the dura were seen and the vague outline of the attachment was identified. At the final inspection after tumor removal, perforators to the brain, optic nerves, chiasm, and pituitary stalk were visualized. ICG fluorescence signals from the hypophyseal arteries were strong enough to see and spread to the area of perfusion with the passage of time. The ICA and the patent cavernous sinus were detected with the ICG endoscope in real time and at high resolution. The ICG endoscope is very useful during ETSS. The authors suggest that the real-time observation of the blood supply to the optic nerves and pituitary helps to predict the preservation of their function.

Usefulness of an Image Fusion Model Using Three-Dimensional CT and MRI with Indocyanine Green Fluorescence Endoscopy as a Multimodal Assistant System in Endoscopic Transsphenoidal Surgery.

Purpose. We investigate the usefulness of multimodal assistant systems using a fusion model of preoperative three-dimensional (3D) computed tomography (CT) and magnetic resonance imaging (MRI) along with endoscopy with indocyanine green (ICG) fluorescence in establishing endoscopic endonasal transsphenoidal surgery (ETSS) as a more effective treatment procedure. Methods. Thirty-five consecutive patients undergoing ETSS in our hospital between April 2014 and March 2015 were enrolled in the study. In all patients, fusion models of 3D-CT and MRI were created by reconstructing preoperative images. In addition, in 10 patients, 12.5 mg of ICG was intravenously administered, allowing visualization of surrounding structures. We evaluated the accuracy and utility of these combined modalities in ETSS. Results. The fusion model of 3D-CT and MRI clearly demonstrated the complicated structures in the sphenoidal sinus and the position of the internal carotid arteries (ICAs), even with extensive tumor infiltration. ICG endoscopy enabled us to visualize the surrounding structures by the phasic appearance of fluorescent signals emitted at specific consecutive elapsed times. Conclusions. Preoperative 3D-CT and MRI fusion models with intraoperative ICG endoscopy allowed distinct visualization of vital structures in cases where tumors had extensively infiltrated the sphenoidal sinus. Additionally, the ICG endoscope was a useful real-time monitoring tool for ETSS.

Visualization of blood supply route to the reconstructed stomach by indocyanine green fluorescence imaging during esophagectomy.

BackgroundEnsuring an adequate blood supply is essential to the safe performance of an anastomosis during esophagectomy and the prevention of anastomotic leakage. Recently, indocyanine green (ICG) fluorescence imaging has been used to visualize the blood supply when anastomosis is performed in vascular surgery. We used ICG fluorescence imaging to visualize the blood supply for reconstruction during esophagectomy.MethodsSince January 2009, we have performed ICG fluorescence imaging in 33 patients with thoracic esophageal cancer who underwent thoracic esophagectomy. After pulling up the reconstructed stomach, 2.5 mg of ICG was injected as a bolus. ICG fluorescence imaging was performed with a near-infrared camera, and the images were recorded.ResultsICG fluorescence was easily detected in all patients 1 min after injection. Vascular networks were well visualized in the gastric wall and omentum. The blood supply route was located in the greater omentum beside the splenic hilum in 22 (66.7%) of the 33 patients.ConclusionsICG fluorescence can be used to evaluate the blood supply to the reconstructed stomach in patients undergoing esophagectomy for esophageal cancer. On ICG fluorescence imaging, the splenic hiatal vessels were the major blood supply for the anastomosis in most patients.

Indocyanine Green (ICG) Fluorescent Cholangiography During Robotic Cholecystectomy

Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Detection of Sentinel Nodes for Endometrial Cancer With Robotic Assisted Fluorescence Imaging: Cervical Versus Hysteroscopic Injection

Sentinel lymph node (SLN) mapping with indocyanine green (ICG) detected by robotic near infrared (NIR) imaging is a feasible technique. The optimal site of injection (cervical or endometrial) for endometrial cancer has yet to be determined. We prospectively evaluated SLN mapping after cervical and endometrial injections of ICG to compare the detection rates and patterns of nodal distribution. Twenty-nine subjects with endometrial cancer undergoing robotic hysterectomy with lymphadenectomy by a single surgeon received SLN mapping with robotic fluorescence imaging. Seventeen patients received cervical injections of 1 mg of ICG and 12 patients received hysteroscopic endometrial injections of 0.5-mg ICG. Detection rates between the 2 groups were compared using Fisher exact tests. Continuous variables such as operating room times and body mass index were compared using t tests. The SLN detection rate was 82% (14/17) for cervical and 33% (4/12) for hysteroscopic injection (P = 0.027). Sentinel lymph nodes were seen bilaterally in 57% (8/14) of the cervical injection group and 50% (2/4) of the hysteroscopic group. Para-aortic SLNs were seen in 71% (10/14) of patients who mapped after cervical injection and 75% (3/4) patients who mapped after hysteroscopic injection. There was 1 false-negative SLN in the cervical injection group. Cervical ICG injection achieves a higher SLN detection rate and a similar anatomic nodal distribution as hysteroscopic endometrial injection for SLN mapping in patients with endometrial cancer.