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Kleiss SF, Michi M, Schuurman SN, de Vries JPP, Werker PM, de Jongh SJ. Tissue perfusion in DIEP flaps using Indocyanine Green Fluorescence Angiography, Hyperspectral imaging, and Thermal imaging. JPRAS Open 2024; 41:61-74. [PMID: 38948075 PMCID: PMC11214344 DOI: 10.1016/j.jpra.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/02/2024] Open
Abstract
Flap necrosis continues to occur in skin free flap autologous breast reconstruction. Therefore, we investigated the benefits of indocyanine green angiography (ICGA) using quantitative parameters for the objective, perioperative evaluation of flap perfusion. In addition, we investigated the feasibility of hyperspectral (HSI) and thermal imaging (TI) for postoperative flap monitoring. A single-center, prospective observational study was performed on 15 patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction (n=21). DIEP-flap perfusion was evaluated using ICGA, HSI, and TI using a standardized imaging protocol. The ICGA perfusion curves and derived parameters, HSI extracted oxyhemoglobin (oxyHb) and deoxyhemoglobin (deoxyHb) values, and flap temperatures from TI were analyzed and correlated to the clinical outcomes. Post-hoc quantitative analysis of intraoperatively collected data of ICGA application accurately distinguished between adequately and insufficiently perfused DIEP flaps. ICG perfusion curves identified the lack of arterial inflow (n=2) and occlusion of the venous outflow (n=1). In addition, a postoperatively detected partial flap epidermolysis could have been predicted based on intraoperative quantitative ICGA data. During postoperative monitoring, HSI was used to identify impaired perfusion areas within the DIEP flap based on deoxyHb levels. The results of this study showed a limited added value of TI. Quantitative, post-hoc analysis of ICGA data produced objective and reproducible parameters that enabled the intraoperative detection of arterial and venous congested DIEP flaps. HSI appeared to be a promising technique for postoperative flap perfusion assessment. A diagnostic accuracy study is needed to investigate ICGA and HSI parameters in real-time and demonstrate their clinical benefit.
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Affiliation(s)
- Simone F. Kleiss
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Marlies Michi
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Simone N. Schuurman
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Jean-Paul P.M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M.N. Werker
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Steven J. de Jongh
- Department of Plastic Surgery, University Medical Center Groningen, Groningen, The Netherlands
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2
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Hoffman JT, Heuvelings DJI, van Zutphen T, Stassen LPS, Kruijff S, Boerma EC, Bouvy ND, Heeman WT, Al-Taher M. Real-time quantification of laser speckle contrast imaging during intestinal laparoscopic surgery: successful demonstration in a porcine intestinal ischemia model. Surg Endosc 2024:10.1007/s00464-024-11076-3. [PMID: 39020119 DOI: 10.1007/s00464-024-11076-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/08/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) is a dreaded complication following colorectal cancer surgery, impacting patient outcome and leads to increasing healthcare consumption as well as economic burden. Bowel perfusion is a significant modifiable factor for anastomotic healing and thus crucial for reducing AL. AIMS The study aimed to calculate a cut-off value for quantified laser speckle perfusion units (LSPUs) in order to differentiate between ischemic and well-perfused tissue and to assess inter-observer reliability. METHODS LSCI was performed using a porcine ischemic small bowel loop model with the PerfusiX-Imaging® system. An ischemic area, a well-perfused area, and watershed areas, were selected based on the LSCI colormap. Subsequently, local capillary lactate (LCL) levels were measured. A logarithmic curve estimation tested the correlation between LSPU and LCL levels. A cut-off value for LSPU and lactate was calculated, based on anatomically ischemic and well-perfused tissue. Inter-observer variability analysis was performed with 10 observers. RESULTS Directly after ligation of the mesenteric arteries, differences in LSPU values between ischemic and well-perfused tissue were significant (p < 0.001) and increased significantly throughout all following measurements. LCL levels were significantly different (p < 0.001) at both 60 and 120 min. Logarithmic curve estimation showed an R2 value of 0.56 between LSPU and LCL values. A LSPU cut-off value was determined at 69, with a sensitivity of 0.94 and specificity of 0.87. A LCL cut-off value of 3.8 mmol/L was found, with a sensitivity and specificity of 0.97 and 1.0, respectively. There was no difference in assessment between experienced and unexperienced observers. Cohen's Kappa values were moderate to good (0.52-0.66). CONCLUSION Real-time quantification of LSPUs may be a feasible intraoperative method to assess tissue perfusion and a cut-off value could be determined with high sensitivity and specificity. Inter-observer variability was moderate to good, irrespective of prior experience with the technique.
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Affiliation(s)
- J Tim Hoffman
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands.
- University Medical Centre Groningen, Optical Molecular Imaging Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
- LIMIS Development, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands.
| | - Danique J I Heuvelings
- NUTRIM, Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Tim van Zutphen
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands
| | - Laurents P S Stassen
- NUTRIM, Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Solnavägen 1, Solna, 171 77, Stockholm, Sweden
| | - E Christiaan Boerma
- Faculty Campus Fryslân, University of Groningen, Wirdumerdijk 34, 8911 CE, Leeuwarden, The Netherlands
| | - Nicole D Bouvy
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Wido T Heeman
- University Medical Centre Groningen, Optical Molecular Imaging Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Surgery, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
- LIMIS Development, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - Mahdi Al-Taher
- Department of Surgery, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
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3
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Sun X, Peng Y, He P, Cheng H, Li D, Liu H, Lin H, Liu G. Repurposing indocyanine green: exploring the potential of an old drug in modern medicine. NANOSCALE 2024; 16:11411-11428. [PMID: 38860512 DOI: 10.1039/d4nr00283k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
The repurposing of existing drugs, referred to as theranostics, has made profound impacts on precision medicine. Indocyanine green (ICG), a well-established and clinical dye, has continued to be a star agent, described as a multifunctional molecule with concurrent photo- or sono-sensitiveness capabilities and co-delivery accessibility, showing remarkable potential in the area of unimodal or multimodal imaging-guided therapy of various diseases, leading to the extensive consideration of immediate clinical translations. In this review, we strive to bring the understanding of repurposing performance assessment for ICG into practice by clarifying the relationships between its features and applicability. Specifically, we address the obstacles encountered in the process of developing an ICG repurposing strategy, as well as the noteworthy advancements made in the field of ICG repurposing. We also go into detail about the structure-function correlations of drugs containing ICG and how different structural groups significantly affect the physicochemical properties.
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Affiliation(s)
- Xinfei Sun
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Yisheng Peng
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Pan He
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Hongwei Cheng
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Dong Li
- College of Ocean Food and Biological Engineering, Jimei University, Xiamen 361021, China
| | - Huanhuan Liu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Huirong Lin
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
| | - Gang Liu
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics & Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen 361102, China.
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Pasternak JD. Finding Parathyroid Glands. Festchrift: Dr. Janice L Pasieka Oct 14, 2023. Am J Surg 2024; 232:152-153. [PMID: 38383164 DOI: 10.1016/j.amjsurg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/23/2023] [Accepted: 01/17/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Jesse D Pasternak
- Section Endocrine Surgery, University Health Network, University of Toronto, Canada.
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5
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Vonk J, Dierckx RAJO, Keereweer S, Vahrmeijer AL, Verburg FA, Kruijff S. Why and how optical molecular imaging should further be catalyzed by nuclear medicine and molecular imaging: report from the EANM piloting group. Eur J Nucl Med Mol Imaging 2024:10.1007/s00259-024-06729-3. [PMID: 38787394 DOI: 10.1007/s00259-024-06729-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
- J Vonk
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherlands.
| | - R A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherlands
| | - S Keereweer
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Verburg
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Kruijff
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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6
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van Dam MA, Bijlstra OD, Faber RA, Warmerdam MI, Achiam MP, Boni L, Cahill RA, Chand M, Diana M, Gioux S, Kruijff S, Van der Vorst JR, Rosenthal RJ, Polom K, Vahrmeijer AL, Mieog JSD. Consensus conference statement on fluorescence-guided surgery (FGS) ESSO course on fluorescence-guided surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107317. [PMID: 38104355 DOI: 10.1016/j.ejso.2023.107317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Fluorescence-guided surgery (FGS) has emerged as an innovative technique with promising applications in various surgical specialties. However, clinical implementation is hampered by limited availability of evidence-based reference work supporting the translation towards standard-of-care use in surgical practice. Therefore, we developed a consensus statement on current applications of FGS. METHODS During an international FGS course, participants anonymously voted on 36 statements. Consensus was defined as agreement ≥70% with participation grade of ≥80%. All participants of the questionnaire were stratified for user and handling experience within five domains of applicability (lymphatics & lymph node imaging; tissue perfusion; biliary anatomy and urinary tracts; tumor imaging in colorectal, HPB, and endocrine surgery, and quantification and (tumor-) targeted imaging). Results were pooled to determine consensus for each statement within the respective sections based on the degree of agreement. RESULTS In total 43/52 (81%) course participants were eligible as voting members for consensus, comprising the expert panel (n = 12) and trained users (n = 31). Consensus was achieved in 17 out of 36 (45%) statements with highest level of agreement for application of FGS in tissue perfusion and biliary/urinary tract visualization (71% and 67%, respectively) and lowest within the tumor imaging section (0%). CONCLUSIONS FGS is currently established for tissue perfusion and vital structure imaging. Lymphatics & lymph node imaging in breast cancer and melanoma are evolving, and tumor tissue imaging holds promise in early-phase trials. Quantification and (tumor-)targeted imaging are advancing toward clinical validation. Additional research is needed for tumor imaging due to a lack of consensus.
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Affiliation(s)
- M A van Dam
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - O D Bijlstra
- Department of Surgery, Leiden University Medical Center, the Netherlands; Department of Surgery, Amsterdam University Medical Centers, the Netherlands
| | - R A Faber
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - M I Warmerdam
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Denmark
| | - L Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Italy
| | - R A Cahill
- Department of Surgery, UCD Centre for Precision Surgery, University College Dublin, Ireland
| | - M Chand
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - M Diana
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - S Gioux
- Intuitive Surgical, Aubonne, Switzerland
| | - S Kruijff
- Department of Surgical Oncology, University Medical Center Groningen, the Netherlands; Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands
| | - J R Van der Vorst
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | | | - K Polom
- The Academy of Applied Medical and Social Sciences, Lotnicza 2, Elblag, Poland; Gastrointestinal Surgical Oncology Department, Greater Poland Cancer Centre, Garbary 15, Poznan, Poland
| | - A L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, the Netherlands.
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7
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Simion L, Ionescu S, Chitoran E, Rotaru V, Cirimbei C, Madge OL, Nicolescu AC, Tanase B, Dicu-Andreescu IG, Dinu DM, Luca DC, Stanculeanu DL, Gheorghe AS, Zob D, Marincas M. Indocyanine Green (ICG) and Colorectal Surgery: A Literature Review on Qualitative and Quantitative Methods of Usage. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1530. [PMID: 37763651 PMCID: PMC10536016 DOI: 10.3390/medicina59091530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/02/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
Background: Due to its many benefits, indocyanine green (ICG) has gained progressive popularity in operating rooms (ORs) globally. This literature review examines its qualitative and quantitative usage in surgical treatment. Method: Relevant terms were searched in five international databases (1. Pubmed, 2. Sciencedirect, 3. Scopus, 4. Oxfordjournals, 5. Reaxys) for a comprehensive literature review. The main benefits of using ICG in colorectal surgery are: intraoperative fluorescence angiography; fluorescence-guided lymph node involvement detection and the sentinel technique; the fluorescent emphasis of a minute liver tumour, counting just 200 tumour cells; facilitation of fistula diagnosis; and tumour tattooing. This methodology can also be used with quantitative characteristics such as maximum intensity, relative maximum intensity, and in-flow parameters such as time-to-peak, slope, and t1/2max. This article concludes that fluorescence surgery with ICG and near-infrared (NIR) light is a relatively new technology that improves anatomical and functional information, allowing more comprehensive and safer tumour removal and the preservation of important structures.
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Affiliation(s)
- Laurentiu Simion
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Sinziana Ionescu
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Elena Chitoran
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Ph.D. Studies, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Vlad Rotaru
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Ph.D. Studies, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ciprian Cirimbei
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Octavia-Luciana Madge
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- University of Bucharest, 030018 Bucharest, Romania
| | - Alin Codrut Nicolescu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Ph.D. Studies, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency Hospital “Prof. Dr. Agrippa Ionescu”, 011356 Bucharest, Romania
| | - Bogdan Tanase
- Clinic of Thoracic Surgery, Bucharest Oncology Institute, 022328 Bucharest, Romania
| | - Irinel-Gabriel Dicu-Andreescu
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Ph.D. Studies, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Denisa Mihaela Dinu
- Surgery Clinic, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Dan Cristian Luca
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
| | - Dana Lucia Stanculeanu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Oncology Clinic, “Prof. Dr. Al. Trestioreanu” Bucharest Oncology Institute, 022328 Bucharest, Romania
| | - Adelina Silvana Gheorghe
- Ph.D. Studies in Oncology, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daniela Zob
- Oncology Department, “Prof. Dr. Al. Trestioreanu” Bucharest Oncology Institute, 022328 Bucharest, Romania
| | - Marian Marincas
- Ist Clinic of General Surgery and Surgical Oncology, Bucharest Oncology Institute, 022328 Bucharest, Romania; (L.S.)
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
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8
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Pollmann L, Juratli M, Roushansarai N, Pascher A, Hölzen JP. Quantification of Indocyanine Green Fluorescence Imaging in General, Visceral and Transplant Surgery. J Clin Med 2023; 12:jcm12103550. [PMID: 37240657 DOI: 10.3390/jcm12103550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/02/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Near-infrared (NIR) imaging with indocyanine green (ICG) has proven to be useful in general, visceral, and transplant surgery. However, most studies have performed only qualitative assessments. Therefore, a systematic overview of all studies performing quantitative indocyanine green evaluation in general, visceral, and transplant surgeries should be conducted. Free term and medical subject heading (MeSH) term searches were performed in the Medline and Cochrane databases until October 2022. The main categories of ICG quantification were esophageal surgery (24.6%), reconstructive surgery (24.6%), and colorectal surgery (21.3%). Concordantly, anastomotic leak (41%) was the main endpoint, followed by the assessment of flap perfusion (23%) and the identification of structures and organs (14.8%). Most studies examined open surgery (67.6%) or laparoscopic surgery (23.1%). The analysis was mainly carried out using manufacturer software (44.3%) and open-source software (15.6%). The most frequently analyzed parameter was intensity over time for blood flow assessment, followed by intensity alone or intensity-to-background ratios for structure and organ identification. Intraoperative ICG quantification could become more important with the increasing impact of robotic surgery and machine learning algorithms for image and video analysis.
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Affiliation(s)
- Lukas Pollmann
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Munster, Germany
| | - Mazen Juratli
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Munster, Germany
| | - Nicola Roushansarai
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Munster, Germany
| | - Andreas Pascher
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Munster, Germany
| | - Jens Peter Hölzen
- Department for General, Visceral and Transplant Surgery, University Hospital Münster, 48149 Munster, Germany
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Sutton PA, van Dam MA, Cahill RA, Mieog S, Polom K, Vahrmeijer AL, van der Vorst J. Fluorescence-guided surgery: comprehensive review. BJS Open 2023; 7:7162090. [PMID: 37183598 PMCID: PMC10183714 DOI: 10.1093/bjsopen/zrad049] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Despite significant improvements in preoperative workup and surgical planning, surgeons often rely on their eyes and hands during surgery. Although this can be sufficient in some patients, intraoperative guidance is highly desirable. Near-infrared fluorescence has been advocated as a potential technique to guide surgeons during surgery. METHODS A literature search was conducted to identify relevant articles for fluorescence-guided surgery. The literature search was performed using Medical Subject Headings on PubMed for articles in English until November 2022 and a narrative review undertaken. RESULTS The use of invisible light, enabling real-time imaging, superior penetration depth, and the possibility to use targeted imaging agents, makes this optical imaging technique increasingly popular. Four main indications are described in this review: tissue perfusion, lymph node assessment, anatomy of vital structures, and tumour tissue imaging. Furthermore, this review provides an overview of future opportunities in the field of fluorescence-guided surgery. CONCLUSION Fluorescence-guided surgery has proven to be a widely innovative technique applicable in many fields of surgery. The potential indications for its use are diverse and can be combined. The big challenge for the future will be in bringing experimental fluorophores and conjugates through trials and into clinical practice, as well as validation of computer visualization with large data sets. This will require collaborative surgical groups focusing on utility, efficacy, and outcomes for these techniques.
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Affiliation(s)
- Paul A Sutton
- The Colorectal and Peritoneal Oncology Centre, Christie Hospital, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Martijn A van Dam
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronan A Cahill
- RAC, UCD Centre for Precision Surgery, University College Dublin, Dublin, Ireland
- RAC, Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sven Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Karol Polom
- Clinic of Oncological, Transplantation and General Surgery, Gdansk Medical University, Gdansk, Poland
| | | | - Joost van der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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10
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St Amour TC, Demarchi MS, Thomas G, Triponez F, Kiernan CM, Solόrzano CC. Educational Review: Intraoperative Parathyroid Fluorescence Detection Technology in Thyroid and Parathyroid Surgery. Ann Surg Oncol 2023; 30:973-993. [PMID: 36481865 DOI: 10.1245/s10434-022-12807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate parathyroid gland (PG) identification is a critical yet challenging component of cervical endocrine procedures. PGs possess strong near-infrared autofluorescence (NIRAF) compared with other tissues in the neck. This property has been harnessed by image- and probe-based near-infrared fluorescence detection systems, which have gained increasing popularity in clinical use for their ability to accurately aid in PG identification in a rapid, noninvasive, and cost-effective manner. All NIRAF technologies, however, cannot differentiate viable from devascularized PGs without the use of contrast enhancement. Here, we aim to provide an overview of the rapid evolution of these technologies and update the surgery community on the most recent advancements in the field. METHODS A PubMed literature review was performed using the key terms "parathyroid," "near-infrared," and "fluorescence." Recommendations regarding the use of these technologies in clinical practice were developed on the basis of the reviewed literature and in conjunction with expert surgeons' opinions. RESULTS The use of near-infrared fluorescence detection can be broadly categorized as (1) using parathyroid NIRAF to identify both healthy and diseased PGs, and (2) using contrast-enhanced (i.e., indocyanine green) near-infrared fluorescence to evaluate PG perfusion and viability. Each of these approaches possess unique advantages and disadvantages, and clinical trials are ongoing to better define their utility. CONCLUSIONS Near-infrared fluorescence detection offers the opportunity to improve our collective ability to identify and preserve PGs intraoperatively. While additional work is needed to propel this technology further, we hope this review will be valuable to the practicing surgeon.
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Affiliation(s)
- Taylor C St Amour
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marco Stefano Demarchi
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Giju Thomas
- Department of Biomedical Engineering, Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, TN, USA
| | - Frederic Triponez
- Department of Thoracic and Endocrine Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Colleen M Kiernan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solόrzano
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
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11
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Innovations in Parathyroid Localization Imaging. Surg Oncol Clin N Am 2022; 31:631-647. [DOI: 10.1016/j.soc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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12
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Iritani K, Teshima M, Shimoda H, Shinomiya H, Otsuki N, Nibu K. Intraoperative quantitative assessment of parathyroid blood flow during total thyroidectomy using indocyanine green fluorescence imaging ‐ surgical strategies for preserving the function of parathyroid glands. Laryngoscope Investig Otolaryngol 2022; 7:1251-1258. [PMID: 36000062 PMCID: PMC9392388 DOI: 10.1002/lio2.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We investigated the factors affecting postoperative parathyroid gland (PTG) function and devised an objective index to predict the postoperative PTG function during total thyroidectomy. Method This was a retrospective clinical review of 21 consecutive patients who were diagnosed with papillary thyroid carcinoma and underwent total thyroidectomy. The maximum intensity ratio (MIR) was determined as the maximum fluorescence intensity after ICG injection divided by the intensity before ICG injection. Results Postoperative hypoparathyroidism is significantly associated with simultaneous central neck dissection (CND) and lateral neck dissection (LND) (p = .032). The Spearman correlation test showed a moderate correlation between the MIR and iPTH levels (p = .0047). The optimal MIR cutoff value for predicting postoperative hypoparathyroidism was 2.14 with area under the curve = 0.904 (sensitivity: 0.769 and specificity: 1.00). Conclusion CND + LND was significantly associated with postoperative hypoparathyroidism. MIR was found useful in predicting the postoperative PTG function. Level of Evidence: 3b.
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Affiliation(s)
- Keisuke Iritani
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
| | - Masanori Teshima
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
| | - Hikari Shimoda
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
| | - Hirotaka Shinomiya
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
| | - Naoki Otsuki
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
| | - Ken‐ichi Nibu
- Department of Otolaryngology‐Head and Neck Surgery Kobe University Graduate School of Medicine Kobe Japan
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13
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Heterogeneity in Utilization of Optical Imaging Guided Surgery for Identifying or Preserving the Parathyroid Glands—A Meta-Narrative Review. Life (Basel) 2022; 12:life12030388. [PMID: 35330139 PMCID: PMC8955594 DOI: 10.3390/life12030388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Postoperative hypoparathyroidism is the most common complication after total thyroidectomy. Over the past years, optical imaging techniques, such as parathyroid autofluorescence, indocyanine green (ICG) angiography, and laser speckle contrast imaging (LSCI) have been employed to save parathyroid glands during thyroid surgery. This study provides an overview of the utilized methods of the optical imaging techniques during total thyroidectomy for parathyroid gland identification and preservation. Methods: PUBMED, EMBASE and Web of Science were searched for studies written in the English language utilizing parathyroid autofluorescence, ICG-angiography, or LSCI during total thyroidectomy to support parathyroid gland identification or preservation. Case reports, reviews, meta-analyses, animal studies, and post-mortem studies were excluded after the title and abstract screening. The data of the studies were analyzed qualitatively, with a focus on the methodologies employed. Results: In total, 59 articles were included with a total of 6190 patients. Overall, 38 studies reported using parathyroid autofluorescence, 24 using ICG-angiography, and 2 using LSCI. The heterogeneity between the utilized methodology in the studies was large, and in particular, regarding study protocols, imaging techniques, and the standardization of the imaging protocol. Conclusion: The diverse application of optical imaging techniques and a lack of standardization and quantification leads to heterogeneous conclusions regarding their clinical value. Worldwide consensus on imaging protocols is needed to establish the clinical utility of these techniques for parathyroid gland identification and preservation.
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14
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Makovac P, Muradbegovic M, Mathieson T, Demarchi MS, Triponez F. Preliminary experience with the EleVision IR system in detection of parathyroid glands autofluorescence and perfusion assessment with ICG. Front Endocrinol (Lausanne) 2022; 13:1030007. [PMID: 36325460 PMCID: PMC9619109 DOI: 10.3389/fendo.2022.1030007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/27/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Postoperative hypoparathyroidism remains the most frequent complication of neck endocrine surgery. In order to reduce the incidence of this feared complication, several systems for imaging of near infrared autofluorescence (NIRAF) have been invented to help surgeons identify parathyroid glands (PTGs) and evaluate their vascularization. We evaluated the efficacy of the EleVision IR system in thyroid and parathyroid surgery. METHODS We used the EleVision IR system in 25 patients who underwent thyroid/parathyroid surgery or both at our institution between December 2020 and July 2021. At various stages of the surgery, the surgeon first looked for PTGs with the naked eye and then completed the visual inspection with NIRAF imaging. We then compared both the naked eye and NIRAF-supported PTGs detection rates. At the end of surgery, we performed indocyanine green angiography of PTGs in 17 patients. RESULTS In total, we identified 80% of PTGs: 65% with the naked eye only and additional 15% with the assistance of the EleVision IR system. 14 of 17 patients evaluated by ICG angiography had at least one well-vascularized PTG. Only one of these patients (a case of subtotal parathyroidectomy for tertiary hyperparathyroidism) developed symptomatic postoperative hypocalcemia despite a normal parathormone level. The three other patients had at least one remaining moderately-vascularized PTG and only one patient developed transient postoperative hypoparathyroidism. CONCLUSION We concluded that EleVision IR provides an efficient support for identification and evaluation of PTGs, and may be of great assistance in endocrine surgery. The images are easy to interpret even for less experienced surgeons thanks to the different types of color visualization and the possibility to measure the relative fluorescence intensity of PTGs and surrounding tissues.
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15
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Schouw HM, Huisman LA, Janssen YF, Slart RHJA, Borra RJH, Willemsen ATM, Brouwers AH, van Dijl JM, Dierckx RA, van Dam GM, Szymanski W, Boersma HH, Kruijff S. Targeted optical fluorescence imaging: a meta-narrative review and future perspectives. Eur J Nucl Med Mol Imaging 2021; 48:4272-4292. [PMID: 34633509 PMCID: PMC8566445 DOI: 10.1007/s00259-021-05504-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/23/2021] [Indexed: 12/27/2022]
Abstract
Purpose The aim of this review is to give an overview of the current status of targeted optical fluorescence imaging in the field of oncology, cardiovascular, infectious and inflammatory diseases to further promote clinical translation. Methods A meta-narrative approach was taken to systematically describe the relevant literature. Consecutively, each field was assigned a developmental stage regarding the clinical implementation of optical fluorescence imaging. Results Optical fluorescence imaging is leaning towards clinical implementation in gastrointestinal and head and neck cancers, closely followed by pulmonary, neuro, breast and gynaecological oncology. In cardiovascular and infectious disease, optical imaging is in a less advanced/proof of concept stage. Conclusion Targeted optical fluorescence imaging is rapidly evolving and expanding into the clinic, especially in the field of oncology. However, the imaging modality still has to overcome some major challenges before it can be part of the standard of care in the clinic, such as the provision of pivotal trial data. Intensive multidisciplinary (pre-)clinical joined forces are essential to overcome the delivery of such compelling phase III registration trial data and subsequent regulatory approval and reimbursement hurdles to advance clinical implementation of targeted optical fluorescence imaging as part of standard practice. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05504-y.
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Affiliation(s)
- H M Schouw
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - L A Huisman
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Y F Janssen
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - R J H Borra
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A T M Willemsen
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - A H Brouwers
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J M van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - R A Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Diagnostic Sciences, Ghent University Faculty of Medicine and Health Sciences, Gent, Belgium
| | - G M van Dam
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,AxelaRx/TRACER Europe BV, Groningen, The Netherlands
| | - W Szymanski
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - H H Boersma
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre of Groningen, Groningen, The Netherlands
| | - S Kruijff
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands. .,Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands.
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