The safety and feasibility of intraoperative near-infrared fluorescence imaging with indocyanine green in thoracoscopic sympathectomy for primary palmar hyperhidrosis

Application of indocyanine green in thoracic surgery: A review article

Indocyanine green has been used in clinical practice for a long time because of its many advantages such as stable coloration, safety and cheapness. With the widespread development of thoracoscopic technology, thoracic surgeons have a higher demand for the identification of lesions and tissue structures under the thoracoscope, and the traditional white light imaging can no longer fully meet the needs of thoracic surgeons. In this situation, indocyanine green combined with NIR imaging technology has brought great help to thoracic surgeons. For example, indocyanine green plays an important role in the localization of small pulmonary nodules, the imaging of intersegmental lung planes, the imaging of thoracic ducts, and the assessment of blood supply to the tubular stomach. In this paper, we review the application of indocyanine green in thoracic surgery according to the related research and application at home and abroad.

Application of near-infrared fluorescence imaging with indocyanine green in mediastinal surgery

Intraoperative near-infrared (NIR) fluorescence imaging has emerged in recent years and is now used in many surgical procedures. Intraoperative fluorescence imaging can guide surgeons in identifying and localizing specific structures and boundaries, which can facilitate the optimization of surgical procedures. The components of the mediastinum are complex and functionally important, making identifying and locating different structures intraoperatively challenging, and NIR fluorescence imaging has potential clinical value in mediastinal surgery. Here we review the applications of NIR fluorescence imaging technology in mediastinal surgery in recent years.

Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis

PURPOSE

The results and side effects of sympathicotomy for primary palmar hyperhidrosis (PPH) can vary due to anatomical variations of the sympathetic ganglions. The aim of our study was to clarify anatomical variations of the sympathetic ganglions by near-infrared (NIR) thoracoscopy and determine their effects on sympathicotomy for PPH.

METHODS

The cases of 695 consecutive patients with PPH treated with either R3 or R4 sympathicotomy either by normal thoracoscopy or by NIR fluorescent thoracoscopy between March 2015 and June 2021 were retrospectively reviewed and followed up.

RESULTS

The variation rate of third and fourth ganglions was 14.7% and 13.3% on the right side and 8.3% and 11.1% on the left side. Real T3 sympathicotomy (RTS₃) was more effective than real T4 sympathicotomy (RTS₄) in the short-term and long-term follow-up (p < 0.001 and p < 0.001, respectively). RTS₃ was more satisfactory than RTS₄ in the long-term follow-up (p = 0.03), but no significant difference was found in the short-term follow-up (p = 0.24). The incidence and severity of compensatory hyperhidrosis (CH) in the areas of the chest and back in the RTS₄ group were significantly lower than those in the RTS₃ group according to both the short-term results (12.92% vs. 26.19%, p < 0.001; 17.97% vs. 33.33%, p = 0.002, respectively) and the long-term results (19.66% vs. 28.57%, p = 0.017; 21.35% vs. 34.52%, p < 0.001, respectively).

CONCLUSIONS

RTS₃ may be more effective than RTS₄ for PPH. However, RTS₄ appears to be associated with a lower incidence and severity of CH in the areas of the chest and back than RTS_3. NIR intraoperative imaging of thoracic sympathetic ganglions may improve the quality of sympathicotomy surgeries.

Intraoperative fluorescence molecular imaging accelerates the coming of precision surgery in China

Purpose

China has the largest cancer population globally. Surgery is the main choice for most solid cancer patients. Intraoperative fluorescence molecular imaging (FMI) has shown its great potential in assisting surgeons in achieving precise resection. We summarized the typical applications of intraoperative FMI and several new trends to promote the development of precision surgery.

Methods

The academic database and NIH clinical trial platform were systematically evaluated. We focused on the clinical application of intraoperative FMI in China. Special emphasis was placed on a series of typical studies with new technologies or high-level evidence. The emerging strategy of combining FMI with other modalities was also discussed.

Results

The clinical applications of clinically approved indocyanine green (ICG), methylene blue (MB), or fluorescein are on the rise in different surgical departments. Intraoperative FMI has achieved precise lesion detection, sentinel lymph node mapping, and lymphangiography for many cancers. Nerve imaging is also exploring to reduce iatrogenic injuries. Through different administration routes, these fluorescent imaging agents provided encouraging results in surgical navigation. Meanwhile, designing new cancer-specific fluorescent tracers is expected to be a promising trend to further improve the surgical outcome.

Conclusions

Intraoperative FMI is in a rapid development in China. In-depth understanding of cancer-related molecular mechanisms is necessary to achieve precision surgery. Molecular-targeted fluorescent agents and multi-modal imaging techniques might play crucial roles in the era of precision surgery.

Real-time indocyanine green lymphangiography in radical resection of right colon cancer allows the identification of chyle leakage

Chyle leakage can be caused by abdominal surgery and managed successfully without surgical treatment; however, no preventive measures are available. Therefore, we introduce a new method to prevent post-operative chyle leakage.

To investigate the role of indocyanine green (ICG) lymphangiography in the reduction of chyle fistula formation after radical resection of right colon cancer.

Five patients with a diagnosis of right colon cancer undergoing laparoscopic radical colectomy with D3 lymph node dissection were examined in this study. At the end of the operation, two points of 2.5 mg ICG were injected subserosally at the proximal end of the anastomosis (1 ml per point). Then the surgical field was screened by using ICG fluorescence to accurately locate the chyle leakage. Chyle leakage was noted and repaired with a Hem-O-Lock. The volume of output of each drain after surgery was measured daily until the patients were discharged.

We were able to observe ICG fluorescence in the lymphatic vessels within 3 minutes of ICG injection. This visualization allowed us to accurately locate and quickly repair chyle leakage within 5 minutes. Clinical observation after surgery and at a 1-month follow-up showed no chyle leakage in all 5 patients.

Indocyanine green lymphangiography can feasibly guide the location and repair of chyle leakage after right colon cancer resection.

Thoracoscopic excision versus radiofrequency ablation of the sympathetic chain as a treatment for palmar hyperhidrosis: comparative study

Background

Hyperhidrosis is an excess sweat secretion. Various modalities of treatment exist for hyperhidrosis. Although medical treatment is the first line of treatment, its long-term outcome is not satisfactory. In this study, we compared the results of thoracoscopic excision with that of radiofrequency ablation of the sympathetic chain as a treatment of palmar hyperhidrosis.

Results

During the period from January 2014 to December 2017, 42 patients with palmar hyperhidrosis after failure of medical treatment presented to Departments of Pediatric Surgery and Neurosurgery, Faculty of Medicine. They were 26 males and 16 females. Their ages ranged between 11 and 42 years (mean 21.78 years). Twenty patients underwent thoracoscopic excision of the sympathetic chain (in Pediatric Surgery Department), while 22 patients underwent radiofrequency ablation of the sympathetic chain (in Neurosurgery Department). For the thoracoscopic sympathectomy group, the mean operative time was 27.39 min, the mean length of hospital stay was 24.78 h, the mean sweating scale decreased from 3.28 preoperatively to 1.33 1 year postoperatively, and the main postoperative complication was compensatory hyperhidrosis (40%). For the radiofrequency ablation group, the mean operative time was 55 min, the mean length of hospital stay was 20.64 h, the mean sweating scale decreased from 3.29 preoperatively to 1.57 1 year postoperatively, and the main postoperative complication was recurrence of hyperhidrosis (27%).

Conclusion

Thoracoscopic excision is more effective than radiofrequency ablation of the sympathetic chain in improving palmar hyperhidrosis. However, it has a higher risk of developing compensatory hyperhidrosis.