Indocyanine green fluorescence-guided laparoscopic surgery, with omental appendices as fluorescent markers for colorectal cancer resection: a pilot study

Effectiveness and safety of tumor site marking with near-infrared fluorescent clips in colorectal laparoscopic surgery: A case series study

BACKGROUND

In colorectal laparoscopic surgery, accuracy of tumor marking has been an important but not fully resolved issue. The tattoo marking technique or intraoperative endoscopy have been used but they either carry the risk of accidental intestinal puncture or require either longer operation times, a skilled endoscopist and/or intraoperative colon insufflation. We supposed that tumor site marking with the near-infrared fluorescent clips, ZEOCLIP FS clips (Zeon Medical Co., Ltd., Tokyo, Japan) might overcome disadvantages of both tattoo marking and intraoperative endoscopy-based tumor localization methods. This is the first report on the case series using near-infrared fluorescent marking clip. We summarize the early results in 30 patients, who underwent colorectal laparoscopic surgery; we focus particularly on effectiveness and safety of the method.

MATERIALS AND METHODS

Thirty consecutive patients, who underwent laparoscopic surgery for colorectal cancer after previous endoscopic ZEOCLIP FS placement were enrolled from May 2019 till October 2019. The primary endpoint was the rate of intraoperative clip detection and the secondary endpoints were: the rate of adverse effects, percentage of slipped clips and usefulness of plain abdominal radiography to preoperatively confirm the clip retention. Locations of fluorescent clips were identified with a full-color fluorescence laparoscope. All operations and clip placements were performed by the same senior surgeon with sufficient experience in both procedures.

RESULTS

Fluorescent clips could be detected in 94.1% of tumor lesions. Three (2.1%) clips dropped before surgery. Plain abdominal radiography was sufficient to assess clip retention in all cases. No adverse effects related to either clip placement or clip detection were observed.

CONCLUSION

The ZEOCLIP FS could be easily detected from the serosal side of the intestinal tract when placed 1-2 days before surgery. Fluorescent clip-guided laparoscopy may be considered a safe and effective method for localization of colorectal tumor sites. The Research Registry UIN: researchregistry5400.

A novel fluorescent marking clip for laparoscopic surgery of colorectal cancer: A case report

•

This is the first report on fluorescent marking clip for laparoscopic surgery.

•

In laparoscopic surgery, marking of tumor location has been gaining importance.

•

Tattoo marking technique carries the risk of accidental intestinal wall perforation leading to peritoneal scattering or other organ perforation.

•

The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope.

•

The fluorescent clip is expected to reduce risks related to other marking methods.

Introduction

In laparoscopic surgery, marking of tumor location has been gaining importance. Tattoo marking has been often used but the technique carries the risk of accidental peritoneal scattering or other organ injury. We have been involved in the development of a novel fluorescent clip for marking tumor sites and supposed that its usage would reduce risks related to other marking methods.

Case presentation

A 52-year-old man was diagnosed with sigmoid colon cancer and polyp, and was scheduled for laparoscopic sigmoidectomy. On the day before operation, fluorescent clips (ZEOCLIP FS: Zeon Medical co, Ltd, Tokyo) were endoscopically placed around the tumor and polyp sites, 4 clips for each lesion attached every 90 degrees within the colonic lumen, respectively. During the operation, locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE (Medtronic Co., U.S.). Curative operation was performed accordingly with the preoperative pathological and radiological findings. The postoperative course was uneventful.

Discussion

Locations of intraluminally placed fluorescent clips were clearly and easily recognized through the serosal layer of the intestinal wall using a fluorescent laparoscope. Complications related to dye scattering or intestinal wall/other organ perforation were not observed suggesting that future incorporation of this tumor site marking technique into laparoscopic surgery might be beneficial.

Conclusion

The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope. This method is expected to be safe and risks of accidental puncture related to tattoo marking method can be reduced or almost eliminated.