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

Abstract

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

Analysis of safety and efficacy of laparoscopic radical gastrectomy combined with or without indocyanine green tracer fluorescence technique in treatment of gastric cancer: a retrospective cohort study

“…ICG fluorescence laparoscopy has been applied in gastrointestinal surgery in recent years. Several studies have found that, in gastric cancer surgery, preoperative smaller doses of ICG injection in the submucosa around the tumor are conducive to clear imaging of tumor location intraoperatively, and indicate that ICG fluorescence laparoscope could be used to determine the accurate position of intraoperative tumors (18)(19)(20). These studies support the findings of the present study.…”

“…Patients in the ICG group experienced more lymph nodes excisions, which led to relative prolongation of operation time. In their experimental study, Liu et in radical gastrectomy of gastric cancer (19). This was confirmed in the studies of Pang et al, Zhong et al,.…”

“…According to our analysis, this could be more likely to be caused by emboli blocking lymphatic vessels and obstructing lymphatic drainage. A study has found that ICG fluorescence imaging has obvious advantages in lymph node dissection <5 mm, which could be due to the fact that small lymph nodes are more likely to be hidden in fat tissue and are difficult to identify by conventional laparoscopy; lymph node dissection solely based on surgical experience is likely to result in small lymph nodes being missed (19). Previously published studies, as well as the present study, failed to find evidence to confirm the high selectivity of ICG fluorescence imaging in pathologically positive lymph nodes during radical gastrectomy (29,31).…”

Comparison of submucosal and subserosal approaches toward optimized indocyanine green tracer-guided laparoscopic lymphadenectomy for patients with gastric cancer (FUGES-019): a randomized controlled trial

“…The existing injection methods include the submucosal approach (SMA) and subserosal approach (SSA). The results of previous retrospective studies [ 2 , 3 ] and randomized controlled trial (RCT) [ 4 ] showed that submucosal injection of ICG around tumors 1 day before surgery could achieve good tracing of perigastric LNs, thus significantly increasing the overall number of retrieved LNs without increasing surgery-related complications in patients undergoing laparoscopic surgery.…”

New Intraoperative Imaging Tools and Image-Guided Surgery in Gastric Cancer Surgery

“…This facilitated tracing of the dissectible layer and enabled clear identification of the avascular plane as well as the distinction of blood vessels from surrounding lymphatic structures. According to these findings, ICG-enhanced guidance facilitates safe and complete infrapyloric lymph node dissection in terms of precision oncology with shorter operation time and less blood loss [ 16 , 17 ].…”