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

Abstract

BACKGROUND As 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. AIM To investigate whether ICG-enhanced NIR fluorescence-guided imaging is a better technique for LPND in patients with rectal cancer. METHODS A 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. RESULTS Compared 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). CONCLUSION ICG-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.

Rectal cancer lateral pelvic sidewall lymph nodes: a review of controversies and management

“…Indocyanine green (ICG) near‐infrared fluorescence imaging has shown potential for lymph node mapping in colorectal cancer, with sensitivities and specificities of 70–85 per cent 48 . Few data exist to support its use in the context of pelvic sidewall involvement of rectal cancer, but one small study 49 of 42 patients with mid‐to‐low rectal cancers found improved lymph node yield and reduced risk of incomplete LPND with concomitant use of ICG.…”

Indocyanine Green-Enhanced Colorectal Surgery—between Being Superfluous and Being a Game-Changer

“…Zhou et al and Boni et al [ 56 , 57 ] showed the usefulness of ICG in harvesting pelvic lymph nodes during lateral pelvic lymph node dissection, demonstrating that the ease of localization with the help of augmented reality, especially in obese patients, allows for collection of a large number of lymph nodes (11.5 ± 5.9 vs. 7.1 ± 4.8, p = 0.017), with less blood loss (55.8 ± 37.5 mL vs. 108.0 ± 52.7 mL, p = 0.003) and over a shorter period time compared to traditional surgery [ 56 ]. In these studies, the indication of LPLD was established before surgery, not by ICG assessment of SLN on the lateral pelvic wall.…”

“…Up until now, there has been no consensus regarding the use of ICG for lymphatic mapping or SLB, but it has been proven to be useful in the assessment of the lymphatic flow in particular circumstances and it can be a helpful tool during LPLD in rectal cancer surgery. A more targeted dissection brings the benefits of minimal blood loss and reduced damage in the adjacent tissue and can shorten the learning curve for this technique [ 56 , 57 ].…”

Indocyanine Green Fluorescence in Colorectal Cancer

“…As one of the effective treatment methods, laparoscopic LPLN dissection (LPND) can significantly reduce the local recurrence rate compared with simple total mesorectal excision (TME) surgery. In clinical applications, LPND is limited by various complications because the ureters and hypogastric nerves might be damaged without efficient guidance, and for this using ICG improve the dissection increasing the numbers of lymph nodes harvested and decreasing complications [34].…”