Near-Infrared Fluorescence Image-Guided Surgery in Esophageal and Gastric Cancer Operations

Background: Near-infrared fluorescence image-guided surgery helps surgeons to see beyond the classical eye vision. Over the last few years, we have witnessed a revolution which has begun in the field of image-guided surgery. Purpose, and Research design: Fluorescence technology using indocyanine green (ICG) has shown promising results in many organs, and in this review article, we wanted to discuss the 6 main domains where fluorescence image-guided surgery is currently used for esophageal and gastric cancer surgery. Study sample and data collection: Visualization of lymphatic vessels, tumor localization, fluorescence angiography for anastomotic evaluation, thoracic duct visualization, tracheal blood flow analysis, and sentinel node biopsy are discussed. Conclusions: It seems that this technology has already found its place in surgery. However, new possibilities and research avenues in this area will probably make it even more important in the near future

Near-infrared fluorescence guided esophageal reconstructive surgery : a systematic review

BACKGROUND: After an esophagectomy, the stomach is most commonly used to restore continuity of the upper gastrointestinal tract. These esophago-gastric anastomoses are prone to serious complications such as leakage associated with high morbidity and mortality. Graft perfusion is considered to be an important predictor for anastomotic integrity. Based on the current literature we believe Indocyanine green fluorescence angiography (ICGA) is an easy assessment tool for gastric tube (GT) perfusion, and it might predict anastomotic leakage (AL). AIM: To evaluate feasibility and effectiveness of ICGA in GT perfusion assessment and as a predictor of AL. METHODS: This study was designed according to the PRISMA guidelines and registered in the PROSPERO database. PubMed and EMBASE were independently searched by 2 reviewers for studies presenting data on intraoperative ICGA GT perfusion assessment during esophago-gastric reconstruction after esophagectomy. Relevant outcomes such as feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications, were collected by 2 independent researchers. The quality of the included articles was assessed based on the Methodological Index for Non-Randomized Studies. The 19 included studies presented data on 1192 esophagectomy patients, in 758 patients ICGA was used perioperative to guide esophageal reconstruction. RESULTS: The 19 included studies for qualitative analyses all described ICGA as a safe and easy method to evaluate gastric graft perfusion. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (P < 0.001). When poorly perfused cases are excluded from the analyses, the difference in AL was even larger (AL well-perfused group 6.3% vs control group 20.5%, P < 0.001). The AL rate in the group with an altered surgical plan based on the ICG image was 6.5%, similar to the well perfused group (6.3%) and significantly less than the poorly perfused group (47.8%) (P < 0.001), suggesting that the technique is able to identify and alter a potential bad outcome. CONCLUSION: ICGA is a safe, feasible and promising method for perfusion assessment. The lower AL rate in the well perfused group suggest that a good fluorescent signal predicts a good outcome

Quantitative perfusion diagnostics in esophageal cancer surgery

In dit proefschrift wordt gezocht naar een nieuwe techniek om weefselperfusie tijdens operaties in beeld te brengen en te meten, met als doel het optimaliseren van reconstructieve chirurgie en het verlagen van postoperatieve complicaties gepaard gaande met een verminderde perfusie van weefsel. De incidentie van slokdarmkanker stijgt en chirurgie is een hoeksteen in de curatieve behandeling van patiënten met deze ziekte. In 5-20% van de geopereerde patiënten ontstaat door een verminderde weefselperfusie rondom de anastomose een naadlekkage met een hoge morbiditeit en in 2-5% van de patiënten mortaliteit als gevolg. Optische technologieën zouden de ogen van de chirurgen kunnen verbeteren zodat het duidelijker wordt welk weefsel weggesneden moet worden en welk weefsel juist bewaard moet worden. Deel I geeft een overzicht van alle onderzochte lichttechnologieën in de slokdarmchirurgie en de manier waarop deze methoden weefselperfusie in beeld brengen en meten. Daarnaast worden drie lichttechnologieën in een fantoom met de optische eigenschappen van weefsel en nagebootste microvasculatuur in het laboratorium gevalideerd en kwantitatieve parameters voor de beoordelingen van perfusie ontwikkeld. Deel II toont de resultaten van vier veelbelovende technieken; Optical Coherence Tomography, Sidestream Darkfield Microscopy, Laser Speckle Contrast Imaging en Fluorescence Imaging, in een prospectieve studie naar de beeldvorming en meting van intra-operatieve weefselperfusie in patiënten met slokdarmkanker. We concluderen dat voornamelijk de kwantificatie van intra-operatieve perfusie een uitdaging. Perfusie beeldvorming dient gestandaardiseerd uitgevoerd te worden, wil men een uitspraak doen over de kwantitatieve parameters. Met LSCI en FI kunnen we een perfusie-kaart maken om de gunstigste anastomose locatie te tonen

Less Invasive Surgery for Remnant Stomach Cancer After Esophago-proximal Gastrectomy with ICG-guided Blood Flow Evaluation : A Case Report

The standard procedure for remnant gastric cancer after esophago-proximal gastrectomy is total resection of the remnant stomach considering blood supply. However, sometimes surgery may be too invasive due to severe adhesion in the thoracic and mediastinal cavity. The blood supply to the remnant stomach depends on the right gastroepiploic artery and the right gastric artery. Therefore, preservation of the proximal region of the remnant stomach is thought to be anatomically impossible. We report a case of remnant gastric cancer that developed more than 12 years after lower thoracic esophagectomy plus proximal gastrectomy for Siewert Type I squamous cell carcinoma. We used intra-operative indocyanine green (ICG) venous-injection to evaluate blood flow and distal gastrectomy of the remnant stomach was performed by preserving the proximal stomach in the thoracic cavity through an abdominal approach. There were no complications of the remnant stomach or the anastomosis to the jejunum after surgery. In this case, we focused on the blood supply by collateral circulation through the anastomotic line from the remnant esophagus. After confirming blood supply with intra-operative evaluation using ICG fluorescence, less-invasive distal gastrectomy was successfully performed. As the intra-operative ICGbased evaluation for blood supply is a simple and safe method, it might be useful for determining the resection margin of various organs and be effective for the introduction of less invasive surgery. Here, we report a case and a review of the literature

Assessment of the Completeness of Lymph Node Dissection Using Indocyanine Green in Laparoscopic and Robotic Gastrectomy for Gastric Cancer – A Review

More recently, few scientists have attempted to figure out how to improve the careful recognizable proof of the lymphatic waste courses and lymph node stations during radical gastrectomy in this way beginning another examination outskirt in this field called "navigation surgery". Among the distinctive detailed arrangements, the presentation of the indocyanine green has drawn consideration for its attributes, a fluorescence colour that can be identified in the near-infrared spectral band. A fluorescence imaging innovation has been coordinated with frameworks of lymph node dissection in laparoscopic and robotic gastrectomy surgery for gastric cancer. Current confirmations uncover that ongoing vessel navigation by using indocyanine green fluorescence during laparoscopic gastrectomy was demonstrated doable with negligible complications. Its utilization may empower the presentation of fruitful robotic or laparoscopic pylorus-preserving gastrectomy with a decrease in unintended intraoperative wounds, for example, second rate polar dead tissue of the spleen during laparoscopic gastrectomy. The clinical ramifications of utilization of indocyanine green in laparoscopic and robotic gastrectomy for gastric cancer was, in any event, for surgeons with a significant level of involvement with laparoscopic D2 dissection, the near-infrared imaging framework can fill in as a complimentary apparatus to affirm total lymphatic node dissection in patients with atypical life structures. With some restrictions the incorporated innovation of indocyanine green fluorescence with near-infrared imaging systems was practical and a promising strategy for lymphatic mapping in laparoscopic and robotic gastrectomy for gastric cancer

Il ruolo della fluorescenza nella valutazione della perfusione intestinale in chirurgia robotica

La deiscenza anastomotica costituisce una delle principale complicanze in chirurgia colorettale. Oggetto di studio da anni, molti sono i fattori di rischio ad essa correlati ma non su tutti è possibile intervenire riducendone il rischio d'insorgenza. Una corretta perfusione dei monconi è fondamentale per la costruzione di un'anastomosi sana e funzionale. La NIRF è una tecnica innovativa d'imaging intraoperatorio, utilizzata tra l'altro per valutare la vascolarizzazione tissutale. Nel seguente lavoro si analizza l'utilità clinica del sistema robotico Firefly Imaging Sistem nella valutazione della perfusione intestinale nel corso di chirurgia robotica resettiva del colon sinistro/retto

25th International Congress of the European Association for Endoscopic Surgery (EAES) Frankfurt, Germany, 14-17 June 2017 : Oral Presentations

Introduction: Ouyang has recently proposed hiatal surface area (HSA) calculation by multiplanar multislice computer tomography (MDCT) scan as a useful tool for planning treatment of hiatus defects with hiatal hernia (HH), with or without gastroesophageal reflux (MRGE). Preoperative upper endoscopy or barium swallow cannot predict the HSA and pillars conditions. Aim to asses the efficacy of MDCT’s calculation of HSA for planning the best approach for the hiatal defects treatment. Methods: We retrospectively analyzed 25 patients, candidates to laparoscopic antireflux surgery as primary surgery or hiatus repair concomitant with or after bariatric surgery. Patients were analyzed preoperatively and after one-year follow-up by MDCT scan measurement of esophageal hiatus surface. Five normal patients were enrolled as control group. The HSA’s intraoperative calculation was performed after complete dissection of the area considered a triangle. Postoperative CT-scan was done after 12 months or any time reflux symptoms appeared. Results: (1) Mean HSA in control patients with no HH, no MRGE was cm2 and similar in non-complicated patients with previous LSG and cruroplasty. (2) Mean HSA in patients candidates to cruroplasty was 7.40 cm2. (3) Mean HSA in patients candidates to redo cruroplasty for recurrence was 10.11 cm2. Discussion. MDCT scan offer the possibility to obtain an objective measurement of the HSA and the correlation with endoscopic findings and symptoms. The preoperative information allow to discuss with patients the proper technique when a HSA[5 cm2 is detected. During the follow-up a correlation between symptoms and failure of cruroplasty can be assessed. Conclusions: MDCT scan seems to be an effective non-invasive method to plan hiatal defect treatment and to check during the follow-up the potential recurrence. Future research should correlate in larger series imaging data with intraoperative findings