Clinical application of indocyanine green fluorescence imaging in laparoscopic lymph node dissection for intrahepatic cholangiocarcinoma: A pilot study (with video)

A meta-analysis of the value of indocyanine green fluorescence imaging in guiding surgical resection of primary and metastatic liver cancer

OBJECTIVE

This meta-analysis aimed to evaluate the value of indocyanine green fluorescence imaging in precision resection surgery for primary and metastatic liver cancer.

METHODS

A systematic search of PubMed, Embase, Scopus, Cochrane Library, Web of Science, ScienceDirect, and major scientific websites was conducted until June 2024. Randomized controlled trials and observational studies comparing indocyanine green fluorescence imaging-guided liver cancer resection with traditional methods were included. The meta-analysis incorporated overall outcomes and subgroup outcomes based on liver cancer types (primary and metastatic). StataSE 12.0 software was used for statistical analysis after a quality assessment of the included studies.

RESULTS

Twenty studies involving 1,283 patients with liver cancer were included. The results showed that indocyanine green fluorescence imaging significantly reduced intraoperative blood loss [Weighted mean difference (WMD), -88.75; 95 % CI, -128.48 to -49.02, p < 0.05], transfusion rate [Odds ratios (OR), 0.5; 95 % CI, 0.36-0.7, p < 0.05], hospital stay duration [WMD, -1.11; 95 % CI, -1.79 to -0.43, p < 0.05], and the overall complication rate [OR, 0.59; 95 % CI, 0.44-0.79, p < 0.05]. However, no significant differences were observed in operative time or in the subgroup analysis for metastatic liver cancer.

CONCLUSION

Indocyanine green fluorescence imaging is a safe and effective intraoperative navigation technique that improves surgical outcomes and prognostic indicators in liver cancer resection. However, its efficacy in metastatic liver cancer surgery requires further validation through larger-scale, rigorous, prospective, randomized controlled trials.

Real-Time Navigation in Liver Surgery Through Indocyanine Green Fluorescence: An Updated Analysis of Worldwide Protocols and Applications

BACKGROUND

Indocyanine green (ICG) fluorescence has seen extensive application across medical and surgical fields, praised for its real-time navigation capabilities and low toxicity. Initially employed to assess liver function, ICG fluorescence is now integral to liver surgery, aiding in tumor detection, liver segmentation, and the visualization of bile leaks. This study reviews current protocols and ICG fluorescence applications in liver surgery, with a focus on optimizing timing and dosage based on clinical indications.

METHODS

Following PRISMA guidelines, we systematically reviewed the literature up to 27 January 2024, using PubMed and Medline to identify studies on ICG fluorescence used in liver surgery. A systematic review was performed to evaluate dosage and timing protocols for ICG administration.

RESULTS

Of 1093 initial articles, 140 studies, covering a total of 3739 patients, were included. The studies primarily addressed tumor detection (40%), liver segmentation (34.6%), and both (21.4%). The most common ICG fluorescence dose for tumor detection was 0.5 mg/kg, with administration occurring from days to weeks pre-surgery. Various near-infrared (NIR) camera systems were utilized, with the PINPOINT system most frequently cited. Tumor detection rates averaged 87.4%, with a 10.5% false-positive rate. Additional applications include the detection of bile leaks, lymph nodes, and vascular and biliary structures.

CONCLUSIONS

ICG fluorescence imaging has emerged as a valuable tool in liver surgery, enhancing real-time navigation and improving clinical outcomes. Standardizing protocols could further enhance ICG fluorescence efficacy and reliability, benefitting patient care in hepatic surgeries.

Efficacy and safety of indocyanine green fluorescence navigation versus conventional laparoscopic hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Indocyanine green (ICG) fluorescence imaging technology is increasingly widely used in laparoscopic hepatectomy. However, previous studies have produced conflicting results regarding whether it is truly superior to traditional laparoscopic hepatectomy. This study investigated the clinical effect of laparoscopic hepatectomy for hepatocellular carcinoma (HCC) using ICG imaging technology.

METHODS

A systematic review and meta-analysis, based on the preferred reporting items for systematic reviews and meta-analysis statement, were conducted (PROSPERO: CRD42024532356). A computer search was conducted in databases including CNKI, Wanfang, PubMed, Embase, Cochrane Library, and Web of Science from January 1, 1990, to April 30, 2024.

RESULTS

A total of 17 articles were included after screening, comprising 4 randomized controlled trials and 13 case-control studies, with 1620 patients in total. Among these, there were 743 cases in the fluorescence laparoscopy group and 877 cases in the non-fluorescence laparoscopy group. Hepatectomy guided by indocyanine green fluorescence navigation significantly reduced operation time (MD = - 23.25, 95% CI: - 36.35 to - 10.15, P = 0.0005), intraoperative blood loss (MD = - 51.04, 95% CI: - 69.52 to - 32.56, P < 0.00001), and intraoperative transfusion rate (OR = 0.43, 95% CI: 0.27 to 0.69, P = 0.0004), while increasing the R0 resection rate (OR = 2.93, 95% CI: 1.73 to 4.96, P < 0.0001) and decreasing the postoperative complication rate (OR = 0.59, 95% CI: 0.43 to 0.82, P = 0.002). However, there was no statistically significant difference in postoperative length of hospital stay (MD = - 0.67, 95% CI: - 1.51 to 0.18, P = 0.12).

CONCLUSION

In the treatment of HCC, hepatectomy guided by indocyanine green fluorescence navigation demonstrates superior efficacy and safety, its application and promotion are warranted.

Laparoscopic hepatectomy using indocyanine green attenuates postoperative inflammatory response for hepatocellular carcinoma: A propensity score matching analysis

BACKGROUND

Improving the intraoperative and postoperative performance of laparoscopic hepatectomy was quite a challenge for liver surgeons.

AIM

To determine the benefits of indocyanine green (ICG) fluorescence imaging in patients with hepatocellular carcinoma (HCC) who underwent laparoscopic hepatectomy during and after surgery.

METHODS

We retrospectively collected the clinicopathological data of 107 patients who successfully underwent laparoscopic hepatectomy at Zhongshan Hospital (Xiamen), Fudan University from June 2022 to June 2023. Whether using the ICG fluorescence imaging technique, we divided them into the ICG and non-ICG groups. To eliminate statistical bias, a 1:1 propensity score matching analysis was conducted. The comparison of perioperative outcomes, including inflammation-related markers and progression-free survival, was analyzed statistically.

RESULTS

Intraoperatively, the ICG group exhibited lower blood loss, a shorter surgical time, lower hepatic inflow occlusion (HIO) frequency, and a shorter total HIO time. Postoperatively, the participation of ICG resulted in a shorter duration of hospitalization (6.5 vs 7.6 days, P = 0.03) and postoperative inflammatory response attenuation (lower neutrophil-lymphocyte ratio on the first day after surgery and platelet-lymphocyte ratio on the third day, P < 0.05). Although the differences were not significant, the levels of all inflammation-related markers were lower in the ICG group. The rates of postoperative complications and the survival analyses, including progression-free and overall survivals showed no significant difference between the groups.

CONCLUSION

The involvement of ICG fluorescence imaging may lead to improved perioperative outcomes, especially postoperative inflammatory response attenuation, and ultimately improve HCC patients' recovery after surgery.

[Preliminary results of fluorescent lymphography in patients with biliary cancer undergoing liver resection]

OBJECTIVE

To evaluate the diagnostic capability of intraoperative fluorescence lymphography (FLG) in detecting of sentinel lymph nodes (SLN) and lymph outflow pathways in patients with biliary cancer (BC).

MATERIAL AND METHODS

From April 2023 till March 2024, ten liver resections for BC were performed using FLG. We carried out the standard lymph node dissection with additional removal of lymph nodes (LN) that have accumulated indocyanine green (ICG). The lymphatic outflow pathways in all patients and frequency of SLN invasion were evaluated.

RESULTS

Ten patients were included: five patients had been diagnosed with intrahepatic cholangiocarcinoma (IHCC), two - with perichilar tumor (PT), the last three ones had gallbladder cancer (GBC). SLN No. 1 were detected in eight patients, the accumulation of ICG was detected in the following groups of LN: No. 8 (n=2), No. 13 (n=1), No. 12b (n=2), cystic lymph node (n=2), and No. 7 (n=1). SLN No. 2 was detected in seven patients. In three cases LN No. 13 were stained, in one - LN No. 12a, in another - LN No. 8. In two patients, staining of vesicular LN was noted. The combined morphological assessment of SLN No. 1 and SLN No. 2 made it possible to predict the presence of LN metastases in all patients (100%, n=3). Fluorescence of third-order LN was detected in four patients. In one case, the staining of LN No. 13 was noted. Another patient revealed accumulation of ICG in LN No. 3. In two cases, at the third stage, fluorescence of LN No. 7 was noted, while metastatic invasion of LN No. 7 was detected in one patient with IHCC.

CONCLUSION

Using FLG, it was possible to determine an alternative lymph flow outpath to LN No. 7 in three patients. The method allowed to identify and remove metastatic LN No. 7 in one case. 100% sensitivity was shown in the determination of SLN in BC in a small group of patients. It is advisable to study the sensitivity of the method in large-scale studies.

Lymph node metastasis of intrahepatic cholangiocarcinoma: the present and prospect of detection and dissection

Intrahepatic cholangiocarcinoma (ICC) ranks as the second most primary liver cancer that often goes unnoticed with a high mortality rate. Hepatectomy is the main treatment for ICC, but only 15% of patients are suitable for surgery. Despite advancements in therapeutic approaches, ICC has an unfavorable prognosis, largely due to lymph node metastasis (LNM) that is closely linked to the elevated recurrence rates. Consequently, the identification of precise and suitable techniques for the detection and staging of LNM assumes paramount importance for ICC therapy. While preoperative imaging plays a crucial role in ICC diagnosis, its efficacy in accurately diagnosing LNM remains unsatisfactory. The inclusion of lymph node dissection as part of the hepatectomy procedures is significant for the accurate pathological diagnosis of LNM, although it continues to be a topic of debate. The concept of sentinel lymph node in ICC has presented a novel and potentially valuable approach for diagnosing LNM. This review aims to explore the current state and prospects of LNM in ICC, offering a promising avenue for enhancing the clinical diagnosis and treatment of ICC to improve patient prognosis.

Indocyanine Green and Hepatobiliary Surgery: An Overview of the Current Literature

Indocyanine green (ICG) is an inert polypeptide that almost totally binds to high molecular weight plasma proteins; it is cleared by the hepatocytes and directly excreted into the bile with a half-life of about 3-5 minutes. Specific systems are required to see fluorescent images. The use of this dye has been reported in different surgical specialties, and the applications in hepatobiliary surgery are widening. Being firstly used to evaluate the preoperative liver function, intra- and postoperative dynamic checking of hepatic activity has been reported and integrated within perioperative protocols allowing a tailored treatment allocation. Intravenous injection (IV) or injection into the gallbladder can ease difficult cholecystectomy. Biliary leakage detection could be enhanced by IV ICG injection. Although with some contrasting results, the use of ICG for both delineating the limits of the resection and tumor-enhanced visualization was demonstrated to improve short- and long-term outcomes. Although the lack of strong evidence still precludes the introduction of this tool in clinical practice, it harbors great potential in liver surgery.

Pay attention to the application of indocyanine green fluorescence imaging technology in laparoscopic liver cancer resection

Traditional laparoscopic liver cancer resection faces challenges, such as difficulties in tumor localization and accurate marking of liver segments, as well as the inability to provide real-time intraoperative navigation. This approach falls short of meeting the demands for precise and anatomical liver resection. The introduction of fluorescence imaging technology, particularly indocyanine green, has demonstrated significant advantages in visualizing bile ducts, tumor localization, segment staining, microscopic lesion display, margin examination, and lymph node visualization. This technology addresses the inherent limitations of traditional laparoscopy, which lacks direct tactile feedback, and is increasingly becoming the standard in laparoscopic procedures. Guided by fluorescence imaging technology, laparoscopic liver cancer resection is poised to become the predominant technique for liver tumor removal, enhancing the accuracy, safety and efficiency of the procedure.

DNA-Based Near-Infrared Voltage Sensors

Indocyanine green (ICG) is an FDA approved dye widely used for fluorescence imaging in research, surgical navigation, and medical diagnostics. However, ICG has a few drawbacks, such as concentration-dependent aggregation and absorbance, nonspecific cellular targeting, and rapid photobleaching. Here, we report a novel DNA-based nanosensor platform that utilizes monomers of ICG and cholesterol. Using DNA origami, we can attach ICG to a DNA structure, maintaining its concentration, preserving its near-infrared (NIR) absorbance, and allowing attachment of targeting moieties. We characterized the nanosensors' absorbance, stability in blood, and voltage sensing in vitro. This study presents a novel DNA-based ICG nanosensor platform for cellular voltage sensing for future in vivo applications.

Safety and effectiveness of fluorescence laparoscopy in precise hepatectomy: A meta-analysis

BACKGROUND

To perform a systematic review of the safety and effectiveness of fluorescence laparoscopy-guided precise hepatectomy.

METHODS

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases from inception to December 1, 2022, using the search terms "indocyanine green," "ICG," "infracyanine green," "laparoscopy," "liver resection," and "hepatectomy." After performing a methodological quality assessment of the included studies, the overall results were subjected to meta-analysis using Review Manager 5.3.

RESULTS

After screening, the meta-analysis included a total of 13 articles. The studies included 1,115 patients who were grouped into the fluorescence laparoscopy (490 patients) and conventional laparoscopy (625 patients) groups. All articles included in the meta-analysis were of high quality. The results of the meta-analysis revealed that compared to the conventional laparoscopy group, the fluorescence laparoscopy group had a higher R0 resection rate (odds ratio=4.03, 95% confidence interval [1.50, 10.83], P=0.006), lower blood transfusion rate (odds ratio=0.46, 95% confidence interval [0.21, 0.97], P=0.04) and lower blood loss (mean difference=-36.58; 95% confidence interval [-59.75, -13.41], P=0.002). However, the length of hospital stay, operative time, and incidence of postoperative complications did not differ significantly between both groups (P>0.05).

CONCLUSION

Compared to conventional laparoscopy, fluorescence laparoscopy provides better application effects in hepatectomy. The surgical procedure has demonstrated good safety and feasibility, which make it worthy of popularization.

Safety and feasibility of laparoscopic liver resection for intrahepatic cholangiocarcinoma: a propensity score-matched study

BACKGROUND

Laparoscopic liver resection (LLR) is controversial in treating intrahepatic cholangiocarcinoma (ICC). Therefore, this study aimed to evaluate the safety and feasibility of LLR for the treatment of ICC and explored the independent factors affecting the long-term prognosis of ICC.

METHODS

We included 170 patients undergoing hepatectomy for ICC from December 2010 to December 2021 and divided them into LLR group and open liver resection (OLR) group. We used propensity score matching (PSM) analysis to reduce the impact of data bias and confounding variables and then compared the short-term and long-term prognosis of LLR and OLR in treating ICC; Cox proportional hazards regression model was adopted to explore the independent factors affecting the long-term prognosis of ICC.

RESULTS

A total of 105 patients (70 in the LLR group and 35 in the OLR group) were included after 2:1 PSM analysis. There was no difference in demographic characteristics and preoperative indexes between the two groups. The perioperative results of the OLR group were worse than those of the LLR group, that is, the intraoperative blood transfusion rate (24 (68.6) vs 21 (30.0)), blood loss (500 (200-1500) vs 200 (100-525)), and the morbidity of major postoperative complications (9 (25.7) vs 6 (8.5)) in the OLR group were worse than those in LLR group. LLR could enable patients to obtain an equivalent long-term prognosis compared to OLR. The Cox proportional hazards regression model exhibited that no matter before or after PSM, preoperative serum CA12-5 and postoperative hospital stay were independent factors affecting overall survival, while only lymph node metastasis independently influenced recurrence-free survival.

CONCLUSIONS

Compared with ICC treated by OLR, the LLR group obtained superior perioperative period outcomes. In the long run, LLR could enable ICC patients to receive an equivalent long-term prognosis compared to OLR. In addition, ICC patients with preoperative abnormal CA12-5, lymph node metastasis, and more extended postoperative hospital stay might suffer from a worse long-term prognosis. However, these conclusions still need multicenter extensive sample prospective research to demonstrate.

A meta-analysis of short-term and long-term effects of indocyanine green fluorescence imaging in hepatectomy for liver cancer

OBJECTIVES

This meta-analysis aimed to compare the short-term and long-term effects of indocyanine green fluorescence imaging in hepatectomy for liver cancer.

METHODS

The databases PubMed, Embase, Scopus, Cochrane Library, Web of Science, ScienceDirect, and major scientific websites were screened up to January 2023. Randomized controlled trials and observational studies comparing fluorescence navigation-assisted and fluorescence-free navigation-assisted hepatectomy for liver cancer were included. Our meta-analysis comprises overall results and 2 subgroup analyses based on surgery type (laparoscopy and laparotomy). These estimates are presented as mean differences (MD) or odds ratio (OR) estimates with 95% CIs.

RESULTS

We analyzed 16 studies that included 1260 patients with liver cancer. Our results showed that fluorescent navigation-assisted hepatectomy were significantly more shorter than fluorescence-free navigation-assisted hepatectomy in the following parameters: operative time [MD = -16.19; 95% CI: -32.27 to -0.11; p = 0.050], blood loss [MD = -107.90; 95% CI: -160.46 to -55.35; p < 0.001], blood transfusion [OR = 0.5; 95% CI: 0.35 to 0.72; p = 0.0002], hospital stay [MD = -1.60; 95% CI: -2.33 to -0.87; p < 0.001], and postoperative complications [OR = 0.59; 95% CI: 0.42 to 0.82; p = 0.002], The one-year disease-free survival rate [OR = 2.87; 95% CI: 1.64 to 5.02; p = 0.0002] was higher in the fluorescent navigation-assisted hepatectomy group.

CONCLUSIONS

Indocyanine green fluorescence imaging has good clinical value and can improve the short-term and long-term results of hepatectomy for liver cancer.

The focus clinical research in intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC), highly invasive and highly heterogeneous, has a poor prognosis. It has been confirmed that many risk factors are associated with ICC including intrahepatic lithiasis, primary sclerosing cholangitis (PSC), congenital abnormalities of the bile ducts, parasite infection, toxic exposures chronic liver disease (viral infection and cirrhosis) and metabolic abnormalities. In recent years, significant progress has been made in the clinical diagnosis and treatment of ICC. Advances in functional and molecular imaging techniques offer the possibility for more accurate preoperative assessment and detection of recurrence. Moreover, the combination of molecular typing and traditional clinical pathological typing provides accurate guarantee for clinical decision-making. Surgical resection is still the only radical treatment for ICC, while R0 resection, lymph node dissection, postoperative adjuvant therapy and recurrence resectomy have been confirmed to be beneficial for patients. New therapies including local therapy, molecular targeted therapy and immunotherapy are developing rapidly, which brings hopeful future for advanced ICC. The combination of traditional therapy and new therapy is the future development direction.