Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer

Abstract

IMPORTANCEThe application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.OBJECTIVE To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer. DESIGN, SETTING, AND PARTICIPANTSPatients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019. INTERVENTIONSThe ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery. MAIN OUTCOMES AND MEASURES Total number of retrieved lymph nodes.RESULTS Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery.CONCLUSIONS AND RELEVANCE Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially t...

The Short-term and Long-term Outcomes of Indocyanine Green Tracer-Guided Laparoscopic Radical Gastrectomy in Patients with Gastric Cancer

“…retrieve more lymph nodes compared with routine surgery 16,25 . A recent randomized study demonstrated that ICG signi cantly improved the number of lymph node retrieved in D2 lymphadenectomy without increasing the risk of complications 15 . Our study consistently found that ICG could increase the number of lymph nodes retrieved during laparoscopic gastrectomy.…”

“…Traditionally, ICG administration includes subserosal and submucosal injections around the tumor [14][15][16][17]25 . Previous studies suggested that submucosal injection is superior than subserosal injection in intraoperative lymph node detection 14 .…”

“…And subserosal injection often caused ICG leakage and surgical eld blur 17 . Therefore, we adopted submucosal injection of ICG in our study, Previous studies suggested preoperative injection of ICG 15,16 , since they assumed that it takes time for ICG to spread into lymph nodes and prolongs the operation time. Instead, we performed intraoperative injection, and our data showed similar operation time between ICG and non-ICG group.…”

“…It was initially used in sentinel lymph node navigation and anastomotic blood ow visualization 10,12,13 . Recent studies begin to investigate the safety and effectiveness of ICG navigation in lymphadenectomy during laparoscopic radical gastrectomy [14][15][16][17] . However, there lack studies that report the long-term outcome in patients receiving ICG-guided gastrectomy.…”

Advances in laparoscopic surgery for the treatment of advanced gastric cancer in China

“…At present, there is still a global lack of high-level evidence-based medicine to determine whether ICG can help surgeons perform a safe and effective LN dissection. For this reason, the FUGES-012 study was conducted to assess the effectiveness of LN harvest and its safety during laparoscopic ICG-guided radical gastrectomy in patients with GC [52]. There were more retrieved LNs and lower LN noncompliance in the ICG group than in the non-ICG group, with a comparable recovery process.…”