Two cases of laparoscopic deroofing of giant liver cysts using indocyanine green fluorescence imaging

Laparoscopic deroofing (LD) for giant liver cysts using indocyanine green (ICG) fluorescence imaging was performed in two patients: a 53-year-old man with a 26-cm, symptomatic cyst and a 50-year-old woman with a 13-cm, symptomatic cyst. ICG fluorescence imaging can be used to easily identify the boundary between the liver parenchyma and the liver cyst. No postoperative bile leakage was observed in both patients. ICG fluorescence imaging is expected to become a desirable procedure in LD for giant liver cysts to reduce the occurrence of perioperative complications.

Indocyanine green: A novel marker for assessment of graft quality during ex situ normothermic machine perfusion of human livers

BACKGROUND

Ex situ machine perfusion facilitates the assessment of livers prior to transplantation. However, currently available markers of liver function poorly predict long-term graft function. Indocyanine green (ICG) is a liver-specific dye which, although common in vivo, has never been comprehensively evaluated for the assessment of graft quality during ex situ machine perfusion. This study aimed to assess the utility of ICG in the ex situ setting.

METHODS

Using a customized long-term perfusion system, human livers that were not suitable for transplantation were perfused using a red cell-based perfusate. ICG was delivered into the perfusate on days 0, 1, and 4 to assess ICG clearance (spectrophotometric absorbance at 805 nm) and ICG fluorescence (near-infrared camera).

RESULTS

Sixteen partial livers were perfused for a median duration of 172 h (7.2 days). On day 0, the median ICG perfusate disappearance rate (PDR) was 7.5%/min and the median ICG retention at 15 min was 9.9%. Grafts that survived ≥7 days had a significantly higher median ICG PDR on day 0 (14.5%/min vs. 6.5%/min, p = 0.005) but not on days 1 or 4. ICG perfusion demonstrated that long-surviving grafts had a significantly lower median red-value (89.8 vs. 118.6, p = 0.011) and a significantly lower median blue-value (12.9 vs. 22.6, p = 0.045) than short-surviving grafts.

CONCLUSION

ICG is a novel marker for the assessment of liver function during ex situ normothermic machine perfusion. ICG PDR and quantitative ICG perfusion can distinguish between long- and short-surviving grafts and demonstrate the utility of ICG in the assessment of graft quality prior to transplant.

Simultaneous Visualization of Lung Tumor and Intersegmental Plane during Pulmonary Segmentectomy by Intravenous Injection of Indocyanine Green

Segmentectomy is a targeted surgical approach tailored for patients with compromised health and early-stage lung cancer. The key to successful segmentectomy lies in precisely identifying the tumor and intersegmental planes to ensure adequate resection margins. In this study, we aimed to enhance this process by simultaneously visualizing the tumor and intersegmental planes through the intravenous injection of indocyanine green (ICG) at different time points and doses. Lung tumors were detected by intravenous injection of ICG at a dose of 2 mg/kg 12 h before surgery in a rabbit model. Following the dissection of the pulmonary artery, vein, and bronchi of the target segment, 0.6 mg/kg of ICG was injected intravenously to detect the intersegmental plan. Fluorescent images of the lung tumors and segments were acquired, and the fluorescent signal was quantified using the signal-to-background ratio (SBR). Finally, a pilot study of this method was conducted in three patients with lung cancer. In a preclinical study, the SBR of the tumor (4.4 ± 0.1) and nontargeted segments (10.5 ± 0.8) were significantly higher than that of the targeted segment (1.6 ± 0.2) (targeted segment vs. nontarget segment, p < 0.0001; target segment vs. tumor, p < 0.01). Consistent with preclinical results, lung tumors and the intersegmental plane were successfully detected in patients with lung cancer. Consequently, adequate resection margins were identified during the surgery, and segmentectomy was successfully performed in patients with lung cancer. This study is the first to use intravenous ICG injections at different time points and doses to simultaneously detect lung cancer and intersegmental planes, thereby achieving segmentectomy for lung cancer.

Comparative aspects of targeted sentinel lymph node mapping in veterinary and human medicine: opportunities for future research

There is a significant overlap in the genetic, metabolic and epigenetic alterations between human and companion animal cancers, including those of the oral cavity, breast, bladder, skin, lungs and pancreas. In many cancer types, the identification and removal of affected lymph nodes are essential for accurate cancer management, including treatment and prognosis. Historically, lymphadenectomy and subsequent radical resection based on regional anatomy, palpation and lymph node aspirates were considered sufficient; however, modern approaches with sentinel lymph node mapping (SLN) mapping have increased the accuracy of surgical decision-making. Preoperative and intraoperative SLN mapping techniques in veterinary patients parallel those used in human medicine. While many of these techniques are highly successful, the main challenges with current methodologies are their sensitivity and specificity for the presence of cancer, which can be overcome via precision medicine and targeted SLN mapping agents. Given the large population of dogs and cats with cancer, the crossover of knowledge between species can help to deepen our understanding of many of these cancers and can be useful in evaluating new drugs and/or therapies. In this review, we discuss SLN mapping techniques in veterinary medicine and the concept of precision medicine as it relates to targeted SLN mapping imaging agents. The large number of companion animals affected by cancer is an underutilized resource to bridge the translational gap and we aim to provide a reference for the use of dogs and cats as a comparative model for human SLN mapping.

Endoscopic endonasal transsphenoidal surgery for the intrasellar mixed germ cell tumor

Mixed germ cell tumor (MGCT) in the neurohypophysis is very rare, with only a few reported cases,1-4 but none with surgical videos. In this video article, the endoscopic endonasal transsphenoidal approach (EETA) for MGCT in the neurohypophysis is presented.

Efficacy of indocyanine green fluorescence-guided inguinal lymph node dissection for penile cancer: a randomised trial

OBJECTIVES

To investigate the safety and efficacy of indocyanine green (ICG) fluorescence-guided inguinal lymph node dissection (ILND) in patients with penile cancer.

PATIENTS AND METHODS

A prospective, single-blind, randomised controlled clinical trial (ChiCTR2100044584) was performed among patients with penile caner who underwent bilateral modified ILND at four centres in China between 1 April 2021 and 30 June 2022. Patients aged 18-80 years and diagnosed with squamous cell carcinomas were included. Each enrolled patient was randomly assigned to either ICG fluorescence-guided ILND by a laparoscopic or robot-assisted approach in one groin, with non-ICG fluorescence-guided ILND in the other groin acting as a control. The primary outcome was the number of retrieved ILNs. Secondary outcomes included complications according to the Clavien-Dindo classification and the ILN non-compliance (inadequate removal of ILNs) rate.

RESULTS

A total of 45 patients were included in the intention-to-treat (ITT) analysis, and the 42 who completed the entire study were included in the per protocol (PP) analysis. There were no ICG-related complications in any of the patients. The results of the ITT and PP analyses indicated that the total number of unilateral ILNs retrieved was higher on the ICG side than on the non-ICG side (mean 13 vs 9 ILNs, difference 4 ILNs [95% CI 2.7-4.4], P = 0.007), and the number of unilateral deep and superficial ILNs was higher on the ICG side. Furthermore, the LN non-compliance rate was lower on the ICG side than on the non-ICG side. Additionally, there was no significant difference in local complications in the groins between the two sides (P > 0.05).

CONCLUSION

An ICG fluorescence-guided ILND was safe for patients with penile cancer. This procedure can improve the number of ILNs retrieved and reduce the LN non-compliance rate without increased complications. ICG fluorescence-guided ILND is beneficial and recommended for selected patients with penile cancer.

Robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir: A case report

Undergoing another surgery after a previous abdominal procedure can sometimes result in significant abdominal adhesions. We present a case of robot-assisted low anterior resection in a patient with rectal cancer who had a urinary reservoir. A 65-year-old male patient underwent robot-assisted total bladder resection and creation of a urinary reservoir for bladder cancer in 2013. He presented with melena. Thus, the findings revealed advanced low rectal cancer. The robot-assisted low anterior resection was performed in 2022. Extensive adhesions were observed in the pelvic space. The indocyanine green function was appropriately used, and the robotic surgery was completed without injury to the urinary reservoir or major complications. The surgical time was 510 min, and the blood loss volume was 15 mL. The patient had been recurrence free for 12 months following the surgery. Robot-assisted surgery can be beneficial for patients with rectal cancer with significant pelvic adhesions.

Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy

INTRODUCTION

Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue.

METHODS

Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group.

RESULTS

Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size.

CONCLUSIONS

This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

[Preliminary application of indocyanine green fluorescence imaging technology in nasal endoscopic tumor surgery]

Objective:To preliminarily study the practical value of Indocyanine green（ICG） molecular fluorescence imaging technology in nasal endoscopic tumor surgery. Methods:Five patients with tumors related to nasal sinuses, orbital wall and skull base in the Department of Otolaryngology head and Neck Surgery, General Hospital of Xinjiang Military Command from December 2022 to April 2023 were enrolled. Among them, 3 were benign tumors and 2 were malignant tumors. All patients underwent surgery under the guidance of ICG molecular fluorescence imaging. ICG was administered intravenously through cubital vein at a dose of 0.5 mg/kg 12 to 24 h before surgery. Tumors were labeled by fluorescence imaging during the operation. surgeons cleared the tumor tissue strictly according to the labeled range and depth, malignant tumors were further expanded and cleaned according to pathology results. Results:All 5 patients achieved accurate tumor localization with the aid of fluorescence imaging technology. Resections were performed with reference to fluorescent labeling boundaries, all patients achieved complete tumor cleanup or negative margins. Conclusion:For tumor-related surgery under nasal endoscopy, ICG molecular fluorescence imaging technology can not only achieve accurate real-time positioning, but also provide evidence for surgeons to judge tumor boundaries. Therefore, we believe that the technology should have certain practical value in nasal endoscopic tumor surgery.

Near-infrared imaging of head and neck squamous cell carcinoma using indocyanine green that targets the αvβ6 peptide

Significance

Head and neck squamous cell carcinoma (HNSCC) has a particularly poor prognosis. Improving the surgical resection boundary, reducing local recurrence, and ultimately ameliorating the overall survival rate are the treatment goals.

Aim

To obtain a complete surgical resection (R0 resection), we investigated the use of a fluorescent imaging probe that targets the integrin subtype α v β 6 , which is upregulated in many kinds of epithelial cancer, using animal models.

Approach

α v β 6 expression was detected using polymerase chain reaction (PCR) and immunoprotein blotting of human tissues for malignancy. Protein expression localization was observed. α v β 6 and epidermal growth factor receptor (EGFR) were quantified by PCR and immunoprotein blotting, and the biosafety of targeting the α v β 6 probe material was examined using Cell Counting Kit-8 assays. Indocyanine green (ICG) was used as a control to determine the localization of the probe at the cellular level. In vivo animal experiments were conducted through tail vein injections to evaluate the probe's imaging effect and to confirm its targeting in tissue sections.

Results

α v β 6 expression was higher than EGFR expression in HNSCC, and the probe showed good targeting in in vivo and in vitro experiments with a good safety profile.

Conclusions

The ICG-α v β 6 peptide probe is an exceptional and sensitive imaging tool for HNSCC that can distinguish among tumor, normal, and inflammatory tissues.

Indocyanine green-marked fluorescence-guided off-clamp versus intraoperative ultrasound-guided on-clamp robotic partial nephrectomy: Outcomes on surgical procedure

Objectives

To compare surgical and functional outcomes between off-clamp robot-assisted partial nephrectomy with indocyanine-green tumour marking through preliminary superselective embolization and on-clamp robot-assisted partial nephrectomy with intraoperative ultrasound identification of the renal mass.

Material and methods

One hundred and forty patients with a single renal mass underwent indocyanine-green fluorescence-guided off-clamp robot-assisted partial nephrectomy with preoperative superselective embolization (Group A, 70 patients) versus intraoperative ultrasound-guided on-clamp robot-assisted partial nephrectomy without embolization (Group B, 70 patients). We assessed operative time, intraoperative blood loss, complications, length of stay, renal function, need for ancillary procedures and blood transfusions.

Results

Mean tumour size was 24 versus 25 mm in Group A versus Group B (p = 0.19). Mean operative time was 86.5 versus 121.8 min (p = 0.02), mean blood loss was 72.8 versus 214.2 mL (p = 0.02), and mean haemoglobin drop on postoperative day 1 was 1.1 versus 2.6 g/dL (p = 0.04) in Group A versus Group B. One-month creatinine, hospital stay and enucleated tumour volume were comparable. Ten postoperative complications occurred in Group A (13.3%) and 11 in Group B (15.3%). Following superselective embolization, no patients required blood transfusions versus two patients in Group B. Postoperative selective renal embolization was needed in one case per group.

Conclusions

Preoperative superselective embolization of a renal mass with indocyanine-green before off-clamp robot-assisted partial nephrectomy significantly reduces operative time and intraoperative blood loss compared to on-clamp intraoperative ultrasound-guided robot-assisted partial nephrectomy. A longer follow-up is needed to establish the effect on renal function.

Comparison of indocyanine green and blue-stained glue for preoperative localization for pulmonary nodules

Background

In patients with pulmonary nodules undergoing computed tomography (CT)-guided localization procedures, a range of liquid-based materials have been employed to date in an effort to guide video-assisted thoracoscopic surgery (VATS) procedures to resect target nodules. However, the relative performance of these different liquid-based localization strategies has yet to be systematically evaluated. Accordingly, this study was developed with the aim of examining the relative safety and efficacy of CT-guided indocyanine green (IG) and blue-stained glue (BSG) PN localization.

Methods

Consecutive patients with PNs undergoing CT-guided localization prior to VATS from November 2021 - April 2022 were enrolled in this study. Safety and efficacy outcomes were compared between patients in which different localization materials were used.

Results

In total, localization procedures were performed with IG for 121 patients (140 PNs), while BSG was used for localization procedures for 113 patients (153 PNs). Both of these materials achieved 100% technical success rates for localization, with no significant differences between groups with respect to the duration of localization (P = 0.074) or visual analog scale scores (P = 0.787). Pneumothorax affected 8 (6.6%) and 8 (7.1%) patients in the respective IG and BSG groups (P = 0.887), while 12 (9.9%) and 10 (8.8%) patients of these patients experienced pulmonary hemorrhage. IG was less expensive than BSG ($17.2 vs. $165). VATS sublobar resection procedure technical success rates were also 100% in both groups, with no instances of conversion to thoracotomy.

Conclusions

IG and BSG both offer similarly high levels of clinical safety and efficacy when applied for preoperative CT-guided PN localization, with IG being less expensive than BSG.

Impact of indocyanine green on prolonged air leak in minimally invasive segmentectomy

BACKGROUND

Video-assisted thoracoscopic segmentectomies have become the gold standard for the treatment of early-stage non-small cell lung cancer less than two centimeters. The main difficulty is the identification of intersegmental boundary lines which dictate postoperative morbidities.

METHODS

We conducted a retrospective study to compare the perioperative outcomes of patients who underwent minimally invasive segmentectomy using the traditional deflation-inflation method or the novel indocyanine green (ICG) technique. Using a prospectively maintained database, we performed a retrospective analysis of 197 consecutive anatomical segmentectomies, from 2020 to 2023. Clinical effectiveness, postoperative complications, and histological data were compared.

RESULTS

A total of 73 (37%) patients had the inflation-deflation method and 124 (63%) had the intravenous ICG method. There were no significant differences in chest tube duration, prolonged air leak, postoperative complications, and postoperative hospital stays. Surgical margin width was also similar between the two groups. The multivariable analysis confirmed these results. Lastly, intravenous ICG brought no additional value in complex segmentectomies.

CONCLUSION

This monocentric and retrospective analysis found no added value of the intravenous ICG on the perioperative results of minimally invasive segmentectomies. The place of this novel technique in the surgical armamentarium remains to be defined. Specific indications such as complex segmentectomy or patients with chronic pulmonary disease require further study.

Photodynamic therapy with paclitaxel-encapsulated indocyanine green-modified liposomes for breast cancer

Background

Photodynamic therapy (PDT) involves the administration of a photosensitizing agent and irradiation of light at an excitation wavelength that damages tumor cells without causing significant damage to normal tissue. We developed indocyanine green (ICG)-modified liposomes in which paclitaxel (PTX) was encapsulated (ICG-Lipo-PTX). ICG-Lipo-PTX accumulates specifically in tumors due to the characteristics of the liposomes. The thermal and photodynamic effects of ICG and the local release of PTX by irradiation are expected to induce not only antitumor effects but also cancer immunity. In this study, we investigated the antitumor effects of ICG-Lipo-PTX in breast cancer.

Methods

The antitumor effects of ICG-Lipo-PTX were examined in xenograft model mice subcutaneously implanted with KPL-1 human breast cancer cells. ICG-Lipo-PTX, ICG-Lipo, or saline was administered intraperitoneally, and the fluorescence intensity was measured with a fluorescence imaging system (IVIS). Intratumor temperature, tumor volume, and necrotic area of tumor tissue were also compared. Next, we investigated the induction of cancer immunity in an allogeneic transplantation model in which BALB-MC mouse breast cancer cells were transplanted subcutaneously in the bilateral inguinal region. ICG-Lipo-PTX was administered intraperitoneally, and PDT was performed on only one side. The fluorescence intensity measured by IVIS and the bilateral tumor volumes were compared. Cytokine secretory capacity was also evaluated by ELISPOT assay using splenocytes.

Results

In the xenograft model, the fluorescence intensity and temperature during PDT were significantly higher with ICG-Lipo-PTX and ICG-Lipo in tumor areas than in nontumor areas. The fluorescence intensity in the tumor area was reduced to the same level as that in the nonirradiated area after two times of irradiation. Tumor growth was significantly reduced and the percentage of necrotic area in the tumor was higher after PDT in the ICG-Lipo-PTX group than in the other groups. In the allograft model, tumor growth on day 14 in the ICG-Lipo-PTX group was significantly suppressed not only on the PDT side but also on the non-PDT side. In addition, the secretion of interferon-γ and interleukin-2 was enhanced, whereas that of interleukin-10 was suppressed, in the ICG-Lipo-PTX group.

Conclusion

The PDT therapy with ICG-Lipo-PTX may be an effective treatment for breast cancer.

Perfusion Analysis Using High-Definition Indocyanine Green Angiography in Burn Comb Model

Indocyanine green angiography (ICGA) has been widely employed for quantitative evaluation of the rat comb burn model, but the imaging equipment, imaging protocol, and fluorescence data interpretation of ICGA remain unsatisfactory. This study aims to provide better solutions for the application of ICGA in perfusion analysis. The rat comb burn model was established under a series of different comb contact durations, including 10, 20, 25, 30, 35, and 40 s. Indocyanine green angiography was used to analyze wound perfusion. In total, 16 rats were divided into ibuprofen and control groups for the burn model, and their perfusion was compared. A total of 16 identical models were divided into standard- and high-dose indocyanine green (ICG) groups, and ICGA was conducted to investigate the dynamic change in wound fluorescence. Escharectomy was performed under real-time fluorescence mapping and navigation. The results showed that a comb contact duration of 30 s was optimum for the burn model. Indocyanine green angiography could accurately evaluate the histologically determined depth of thermal injury and wound perfusion in the rat comb model. Digital subtraction of residual fluorescence was necessary for multiple comparisons of perfusion. Dynamic changes in fluorescence and necrotic tissues were observed more clearly by high-dose (0.5 mg/kg) ICG in angiography. In conclusion, perfusion analysis by ICGA can be used to assess the histologically determined depth of thermal injury and the impact of a specific treatment on wound perfusion. Indocyanine green angiography can help to identify necrotic tissue. The above findings and related imaging protocols lay the foundation for future research.

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials

AIM

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery.

METHOD

PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool.

RESULTS

Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG.

CONCLUSION

Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Indocyanine green-assisted goniotomy in eyes with hazy cornea

Corneal haze, due to edema or opacity, is a major contraindication for performing ab interno angle surgeries such as goniotomy in children with primary congenital glaucoma (PCG), despite otherwise favorable surgical outcomes expected in these patients. In this case series involving patients of PCG with moderate corneal haze, the authors describe a technique for performing goniotomy in cases with compromised visibility by using indocyanine green (ICG) to aid in the visualization of angle structures. The authors used 0.2% ICG intracamerally, which stained the anterior and posterior trabecular meshwork (TM) with different intensities, before proceeding with goniotomy. The junction between the two zones was discernible due to the contrast imparted by ICG staining, despite poor visibility, allowing the surgeon to incise the TM at the correct site. The possibility of performing goniotomy in such patients with the help of ICG can revolutionize our surgical approach to patients with PCG and corneal edema.

Albumin-indocyanine green evaluation of future liver remnant predicts liver failure after anatomical hepatectomy for hepatocellular carcinoma: A dual-center retrospective study

Aim

The albumin-indocyanine green evaluation (ALICE) score is a useful predictor of post-hepatectomy liver failure (PHLF); however, its usefulness in combination with future liver remnant (FLR), measured by 3-D volumetry, has not been investigated. This study aimed to investigate the relationship between the ALICE of the FLR (ALICE-FLR) score and severe PHLF.

Methods

The clinical data of 215 patients who underwent anatomical hepatectomy for hepatocellular carcinoma without portal vein embolization at two institutes between January 2010 and December 2021 were analyzed retrospectively. PHLF occurrence and severity were determined according to the International Study Group of Liver Surgery's definition. Grades B and C PHLF were defined as severe PHLF. The ALICE-FLR, ALICE scores, and indocyanine green clearance of FLR (ICGK-FLR) were evaluated for severe PHLF prediction.

Results

Severe PHLF was observed in 40 patients (18.6%). The areas under the curve (AUCs) for the ALICE-FLR, ALICE scores, ICGK-FLR, and FLR were 0.76, 0.64, 0.73, and 0.69, respectively. The AUC of the ALICE-FLR score was significantly higher than that of the ALICE score. The ALICE-FLR score was identified as an independent predictor of severe PHLF (the odds ratio for every 0.01 increment in the ALICE-FLR score was 1.24; 95% confidence interval, 1.070-1.453; p = 0.004). Among patients with severe PHLF, the ALICE-FLR score was significantly higher in the grade C than in the grade B PHLF group.

Conclusion

The combination of liver function models, including indocyanine green, albumin, and FLR is considered compatible for predicting severe PHLF.

How to Treat a Cyclist's Nodule?-Introduction of a Novel, ICG-Assisted Approach

BACKGROUND

Perineal nodular induration (PNI) is a benign proliferation of the soft tissue in the perineal region that is associated with saddle sports, especially road cycling. The etiology has not been conclusively clarified; however, repeated microtrauma to the collagen and subcutaneous fat tissue by pressure, vibration and shear forces is considered a mechanical pathomechanism. In this context, chronic lymphedema resulting in the development of fibrous tissue has been suggested as an etiological pathway of PNI. The primary aim of this study was to introduce and elucidate a novel operative technique regarding PNI that is assisted by indocyanine green (ICG). In order to provide some context for this approach, we conducted a comprehensive review of the existing literature. This dual objective aimed to contribute to the existing body of knowledge while introducing an innovative surgical approach for managing PNI.

METHODS

We reviewed publications relating to PNI published between 1990 and 2023. In addition to the thorough review of the literature, we presented our novel surgical approach. We described how this elaborate approach for extensive cases of PNI involves surgical excision combined with tissue doubling and intraoperative ICG visualization for exact lymphatic vessel obliteration to minimize the risk of recurrence based on the presumed context of lymphatic congestion.

RESULTS

The literature research yielded 16 PubMed articles encompassing 23 cases of perineal nodular induration (PNI) or cyclist's nodule. Of these, 9 cases involved females, and 14 involved males. Conservative treatment was documented in 7 cases (30%), while surgical approaches were reported in 16 cases (70%). Notably, a limited number of articles focused on histopathological or radiological characteristics, with a shortage of structured reviews on surgical treatment options. Only two articles provided detailed insights into surgical techniques. Similarly to the two cases of surgical intervention identified in the literature research, the post-operative recovery in our ICG assisted surgical approach was prompt, meaning a return to cycling was possible six weeks after surgery. At the end of the observation period (twelve months after surgery), regular scar formation and no signs of recurrence were seen.

CONCLUSION

We hope that this article draws attention to the condition of PNI in times of increasing popularity of cycling as a sport. We aimed to contribute to the existing body of knowledge through our thorough review of the existing literature while introducing an innovative surgical approach for managing PNI. Due to the successful outcome, the combination of tissue doubling, intraoperative ICG visualization and postoperative negative wound therapy should be considered as a therapeutic strategy in cases of large PNI.

Corrigendum: Clinical feasibility of miniaturized Lissajous scanning confocal laser endomicroscopy for indocyanine green-enhanced brain tumor diagnosis

[This corrects the article DOI: 10.3389/fonc.2022.994054.].

Antibody-Conjugated Polymersomes with Encapsulated Indocyanine Green J-Aggregates and High Near-Infrared Absorption for Molecular Photoacoustic Cancer Imaging

Imaging plays a critical role in all stages of cancer care from early detection to diagnosis, prognosis, and therapy monitoring. Recently, photoacoustic imaging (PAI) has started to emerge into the clinical realm due to its high sensitivity and ability to penetrate tissues up to several centimeters deep. Herein, we encapsulated indocyanine green J (ICGJ) aggregate, one of the only FDA-approved organic exogenous contrast agents that absorbs in the near-infrared range, at high loadings up to ∼40% w/w within biodegradable polymersomes (ICGJ-Ps) composed of poly(lactide-co-glycolide-b-polyethylene glycol) (PLGA-b-PEG). The small Ps hydrodynamic diameter of 80 nm is advantageous for in vivo applications, while directional conjugation with epidermal growth factor receptor (EGFR) targeting cetuximab antibodies renders molecular specificity. Even when exposed to serum, the ∼11 nm-thick membrane of the Ps prevents dissociation of the encapsulated ICGJ for at least 48 h with a high ratio of ICGJ to monomeric ICG absorbances (i.e., I895/I780 ratio) of approximately 5.0 that enables generation of a strong NIR photoacoustic (PA) signal. The PA signal of polymersome-labeled breast cancer cells is proportional to the level of cellular EGFR expression, indicating the feasibility of molecular PAI with antibody-conjugated ICGJ-Ps. Furthermore, the labeled cells were successfully detected with PAI in highly turbid tissue-mimicking phantoms up to a depth of 5 mm with the PA signal proportional to the amount of cells. These data show the potential of molecular PAI with ICGJ-Ps for clinical applications such as tumor margin detection, evaluation of lymph nodes for the presence of micrometastasis, and laparoscopic imaging procedures.

Factors Affecting the Efficiency of Near-Infrared Indocyanine Green (NIR/ICG) in Lymphatic Mapping for Colorectal Cancer: A Systematic Review

As laparoscopy gained global popularity in oncologic surgery, the challenge of detecting lymph nodes spurred researchers to explore innovative techniques and approach the situation from a fresh perspective. While many proposed methods have faded into obscurity, the utilization of indocyanine green (ICG) in the surgical treatment of oncologic patients has continued to advance. The immense potential of this dye is widely acknowledged, yet its full extent and limitations in lymphatic mapping for colorectal cancer remain to be precisely determined. This article aims to assess the magnitude of its potential and explore the constraints based on insights from clinical studies published by pioneering researchers. A systematic review of the existing literature, comprising articles in English, was conducted using the Scopus, PubMed, and Springer Link databases. The search employed keywords such as "colorectal cancer" AND/OR "indocyanine green," "fluorescence" AND/OR "lymphatic mapping" AND/OR "lymph nodes." Initially identifying 129 articles, the application of selection criteria narrowed down the pool to 10 articles, which served as the primary sources of data for our review. Despite the absence of a standardized protocol for the application of ICG in colorectal cancer, particularly in the context of lymphatic mapping, the detection rates have exhibited considerable variation across studies. Nevertheless, all authors unanimously regarded this technique as beneficial and promising. Additionally, it is advocated as an adjunctive tool to enhance the accuracy of cancer staging. Near-infrared (NIR)-enhanced surgery holds the promise of transforming the landscape of oncologic surgery, emerging as a valuable tool for surgeons. However, the absence of a standardized technique and the subjective nature of result assessment impose limitations on the potential of this method. Consequently, it can be inferred that the establishment of a universally accepted protocol, encompassing parameters such as dose, concentration, technique, and site of administration of ICG, along with the optimal time needed for fluorescence visualization, would enhance the outcomes. Emphasizing the accurate selection of patients is crucial to prevent the occurrence of false-negative results.

Comparison of perioperative outcomes of selective arterial clipping guided by near-infrared fluorescence imaging using indocyanine green versus undergoing standard robotic-assisted partial nephrectomy: a systematic review and meta-analysis

BACKGROUND

This study employs a meta-analytic approach to investigate the impact of robotic-assisted partial nephrectomy, with and without near-infrared fluorescence imaging (NIRF-RAPN vs S-RAPN), on patients' perioperative outcomes and postoperative changes in renal function.

MATERIALS AND METHODS

The authors conducted a comprehensive and rigorous systematic review and cumulative meta-analysis of primary outcomes following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), AMSTAR (Assessing the Methodological Quality of Systematic Reviews) Guidelines, and Risk-of-Bias Tool (RoB2). To ensure a thorough search, the authors systematically searched five major databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, from databases' inception to April 2023.

RESULTS

No significant differences were found between the two groups in terms of age ( P =0.19), right side ( P =0.54), BMI ( P =0.39), complexity score ( P =0.89), tumor size ( P =0.88), operating time ( P =0.39), estimated blood loss ( P =0.47), length of stay ( P =0.87), complications ( P =0.20), transfusion ( P =0.36), and positive margins ( P =0.38). However, it is noteworthy that the NIRF-RAPN group exhibited significant reductions in warm ischemia time ( P =0.001), the percentage change in estimated glomerular filtration rate at discharge ( P =0.01) compared to the S-RAPN group.

CONCLUSION

This meta-analysis provides evidence that the group undergoing NIRF-RAPN showed a statistically significant protective effect on the estimated glomerular filtration rate (eGFR).

Multifunctional ZnO@DOX/ICG-LMHP Nanoparticles for Synergistic Multimodal Antitumor Activity

Multifunctional nanoparticles are of significant importance for synergistic multimodal antitumor activity. Herein, zinc oxide (ZnO) was used as pH-sensitive nanoparticles for loading the chemotherapy agent doxorubicin (DOX) and the photosensitizer agent indocyanine green (ICG), and biocompatible low-molecular-weight heparin (LMHP) was used as the gatekeepers for synergistic photothermal therapy/photodynamic therapy/chemotherapy/immunotherapy. ZnO was decomposed into cytotoxic Zn2+ ions, leading to a tumor-specific release of ICG and DOX. ZnO simultaneously produced oxygen (O2) and reactive oxygen species (ROS) for photodynamic therapy (PDT). The released ICG under laser irradiation produced ROS for PDT and raised the tumor temperature for photothermal therapy (PTT). The released DOX directly caused tumor cell death for chemotherapy. Both DOX and ICG also induced immunogenic cell death (ICD) for immunotherapy. The in vivo and in vitro results presented a superior inhibition of tumor progression, metastasis and recurrence. Therefore, this study could provide an efficient approach for designing multifunctional nanoparticles for synergistic multimodal antitumor therapy.

Optimizing Indocyanine Green Dosage for Near-Infrared Fluorescence Perfusion Assessment in Bowel Anastomosis: A Prospective, Systematic Dose-Ranging Study

BACKGROUND

Indocyanine green (ICG) near-infrared fluorescence (NIRF) has emerged as a promising technique for visualizing tissue perfusion. However, within the wide range of dosages and imaging conditions currently being applied, the optimal dosage of ICG remains unclear. This study aimed to investigate the feasibility and implications of implementing lower dosages of ICG than commonly used for visual and quantitative perfusion assessment in a standardized setting.

METHODS

A prospective single-center cohort study was conducted on patients undergoing ileostomy reversal by hand-sewn anastomosis. ICG-NIRF visualization was performed before (T1) and after (T2) anastomosis with one of four different dosages of ICG (5 mg, 2.5 mg, 1.25 mg, or 0.625 mg) and recorded. Postoperatively, each visualization was evaluated for signal strength, completeness, and homogeneity of fluorescence. Additionally, perfusion graphs were generated by a software-based quantitative perfusion assessment, allowing an analysis of perfusion parameters. Statistical analysis comparing the effect of the investigated dosages on these parameters was performed.

RESULTS

In total, 40 patients were investigated. Visual evaluation demonstrated strong, complete, and homogeneous fluorescence signals across all dosages. Perfusion graph assessment revealed a consistent shape for all dosages (ingress followed by egress phase). While the average signal intensity decreased with dosage, it was sufficient to enable perfusion assessment even at the lowest dosages of 1.25 mg and 0.625 mg of ICG. The baseline intensity at T2 (the second intraoperative visualization) significantly decreased with dosage. The slope of the egress phase steepened with decreasing dosage.

CONCLUSIONS

Lower dosages of ICG were sufficient for intraoperative perfusion assessment, while causing lower residual fluorescence and quicker egress in subsequent visualizations.

Intraoperative assessment of anastomotic blood supply using indocyanine green fluorescence imaging following esophagojejunostomy or esophagogastrostomy for gastric cancer

Objective

This retrospective study aimed to evaluate the feasibility and safety of intraoperative assessment of anastomotic blood supply in patients undergoing esophagojejunostomy or esophagogastrostomy for gastric cancer using Indocyanine Green Fluorescence Imaging (IGFI).

Materials and methods

From January 2019 to October 2021, we conducted a retrospective analysis of patients who had undergone laparoscopic gastrectomy for the treatment of gastric cancer. The patients were consecutively enrolled and categorized into two study groups: the Indocyanine Green Fluorescence Imaging (IGFI) group consisting of 86 patients, and the control group comprising 92 patients. In the IGFI group, intravenous administration of Indocyanine Green (ICG) was performed, and we utilized a fluorescence camera system to assess anastomotic blood supply both before and after the anastomosis.

Results

The demographic characteristics of patients in both groups were found to be comparable. In the IGFI group, the mean time to observe perfusion fluorescence was 26.3 ± 12.0 seconds post-ICG injection, and six patients needed to select a more proximal resection point due to insufficient fluorescence at their initial site of choice. Notably, the IGFI group exhibited a lower incidence of postoperative anastomotic leakage, with no significant disparities observed in terms of pathological outcomes, postoperative recovery, or other postoperative complication rates when compared to the control group (p > 0.05).

Conclusion

This study underscores the potential of IGFI as a dependable and pragmatic tool for the assessment of anastomotic blood supply following esophagojejunostomy or esophagogastrostomy for gastric cancer. The use of IGFI may potentially reduce the occurrence of postoperative anastomotic leakage.

Evolution of Indocyanine Green Fluorescence in Breast and Axilla Surgery: An Australasian Experience

The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing future research evaluating its use for predicting mastectomy skin flap perfusion for reconstruction, lymphatic mapping for sentinel lymph node (SLN) biopsy, and axillary reverse mapping (ARM) for prevention of lymphoedema. In the authors' experience, routine use of ICG angiography during breast reconstruction postmastectomy was demonstrated to be cost-effective for the reduction of ischemic complications in the Australian setting. A novel tracer combination, ICG-technetium-99m offered a safe and effective substitute to the "gold standard" dual tracer for SLN biopsy, although greater costs were associated with ICG. An ongoing trial will evaluate ARM node identification using ICG fluorescence during axillary lymph node dissection and potential predictive factors of ARM node involvement. These data add to the growing literature on ICG and allow future research to build on this to improve understanding of the potential benefits of fluorescence-guided surgery in breast cancer and reconstruction surgery.

Evaluating Arterialized Vein in Thumb Replantation using Indocyanine Green Angiography: A Case Report

BACKGROUND The absence of valid vessels for the anastomosis constitutes a contraindication to replantation, but the need for arterial vessels in good condition has recently been questioned and some authors have proposed the arterialization of the veins with promising results. However, this method is not routine in replantation and it is unclear what conditions can establish venous congestion and loss of the replanted segment. CASE REPORT We detail a case where indocyanine green aids in evaluating arterialization of a vein during thumb replantation in a 40-year-old smoker following a crush injury. Multiple attempts to anastomose the princeps pollicis and its collateral vessel failed due to a thrombus formation, leaving the finger non-perfused despite urokinase treatment. To confirm the absence of reperfusion, we administered 0.3 mg/kg of indocyanine green through an upper limb peripheral vein. Observing no reperfusion, we located a suitable radial dorsal vein and performed an arteriovenous anastomosis at the proximal phalanx level. Indocyanine Green Angiography (IGA) revealed a slightly delayed reperfusion but a effective venous outflow. We did not consider it necessary to perform additional venous anastomoses other than the single dorsal radial venous anastomosis. CONCLUSIONS This single case report shows the potential of indocyanine green as a valid aid to evaluate the perfusion of the replantation and also any early venous congestion, being able to modify the operative plan accordingly.

The use of indocyanine green in partial nephrectomy: a systematic review

Introduction

The aim of this review was to assess the outcomes of partial nephrectomy using indocyanine green (ICG) regarding ischemia time, positive surgical margins (PSM), estimated blood loss (EBL) and estimated GFR reduction while also suggesting the optimal dosage scheme.

Material and methods

A systematic review was performed using Medline (PubMed), ClinicalTrials.gov, and Cochrane Library (CENTRAL) databases, in concordance with the PRISMA statement. Studies in English regarding the use of indocyanine green in partial nephrectomy were reviewed. Reviews and meta-analyses, editorials, perspectives, and letters to the editors were excluded.

Results

Individual ICG dose was 5 mg in most of the studies. The mean warm ischemia time (WIT) on each study ranged from 11.6 minutes to 27.2 minutes. The reported eGFR reduction ranged from 0% to 15.47%. Lowest mean EBL rate was 48.2 ml and the highest was 347 ml. Positive surgical margin rates were between 0.3% to 11%.

Conclusions

Indocyanine green seems to be a useful tool in partial nephrectomy as it can assist surgeons in identifying tumor and its related vasculature. Thereby, warm ischemia time can be reduced and, in some cases, selective ischemia can be implemented leading to better renal functional preservation.

Safety and effectiveness of indocyanine green fluorescence imaging-guided laparoscopic hepatectomy for hepatic tumor: a systematic review and meta-analysis

Introduction

Previous clinical investigations have reported inconsistent findings regarding the feasibility of utilizing indocyanine green fluorescence imaging (ICGFI) in laparoscopic liver tumor removal. This meta-analysis aims to comprehensively evaluate the safety and effectiveness of ICGFI in laparoscopic hepatectomy (LH).

Methods

A systematic search of pertinent clinical studies published before January 30th, 2023 was conducted in databases including PubMed, Embase, Cochrane, and Web of Science. The search strategy encompassed key terms such as "indocyanine green fluorescence," "ICG fluorescence," "laparoscopic hepatectomy," "hepatectomies," "liver Neoplasms," "hepatic cancer," and "liver tumor." Additionally, we scrutinized the reference lists of included articles to identify supplementary studies. we assessed the quality of the incorporated studies and extracted clinical data. Meta-analysis was performed using STATA v.17.0 software. Either a fixed-effects or a random-effects model was employed to compute combined effect sizes, accompanied by 95% confidence intervals (CIs), based on varying levels of heterogeneity.

Results

This meta-analysis encompassed eleven retrospective cohort studies, involving 959 patients in total. Our findings revealed that, in comparison to conventional laparoscopic hepatectomy, patients receiving ICGFI-guided LH exhibited a higher R0 resection rate (OR: 3.96, 95% CI: 1.28, 12.25, I2 = 0.00%, P = 0.778) and a diminished incidence of intraoperative blood transfusion (OR: 0.42, 95% CI: 0.22, 0.81, I 2 = 51.1%, P = 0.056). Additionally, they experienced shorter postoperative hospital stays (WMD: -1.07, 95% CI: -2.00, -0.14, I 2 = 85.1%, P = 0.000). No statistically significant differences emerged between patients receiving ICGFI-guided LH vs. those undergoing conventional LH in terms of minimal margin width and postoperative complications.

Conclusion

ICGFI-guided LH demonstrates marked superiority over conventional laparoscopic liver tumor resection in achieving R0 resection and reducing intraoperative blood transfusion rates. This technique appears to hold substantial promise. Nonetheless, further studies are needed to explore potential long-term benefits associated with patients undergoing ICGFI-guided LH.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD 42023398195.

Identification of Structures Labeled by Indocyanine Green in the Rat Choroid and Retina Can Guide Interpretation of Indocyanine Green Angiography

Purpose

Indocyanine green (ICG) is an albumin and lipoprotein binding dye absorbing in the far red used in angiography to visualize choroidal vessels (ICG angiography [ICGA]). To guide interpretation, ICG transport in the choroid, RPE, and retina of rats was studied.

Methods

Two conditions were used: RPE/choroid organoculture, incubated for 45 minutes in DMEM medium, 1% fetal bovine serum containing 0.25 mg/mL ICG and RPE/choroid and neural retina flat-mounts at 1 and 6 hours after intravenous ICG injection. Early and late sequences of ICGA were recorded until 6 hours. Ultra-deep red confocal microscope was used to localize ICG in flat-mounts and immunohistochemistry was performed for caveolin-1, tryptase (mast cell marker), and tubulin β3 (a nerve marker).

Results

In the organoculture, ICG penetrated homogeneously in the cytoplasm and stained the membranes of the RPE. At 1 hour after intravenous injection, ICG appeared in fine granules in RPE, partly labeled with caveolin-1 and decreasing at 6 hours. At 1 hour and 6 hours, ICG was found in the retinal vessels, faintly in the inner retina, and in the photoreceptor outer segments at 6 hours. In the choroid, ICG colocalized with mast cells, immunostained with tryptase, and accumulated along the large tubulin β3-labeled nerve bundles. The hypothesis was raised on the interpretation of late ICGA infrared photography in case of transthyretin amyloidosis with neuropathy.

Conclusions

Beside being a vascular dye, ICG is transported from the vessels to the RPE toward the outer retina. It stains mast cells and large choroidal nerves. These observations could help the analysis of ICGA images.

OSATS scoring confirms ICG enhancement of performance in laparoscopic radical gastrectomy: a post-hoc analysis of a randomized controlled trial

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is effective in increasing the number of lymph node dissections during laparoscopic radical gastrectomy; however, no studies have attempted to explain this phenomenon.

METHODS

This study utilized the data from a previous randomized controlled trial (FUGES-012 study) investigating ICG-guided laparoscopic radical gastrectomy performed between November 2018 and July 2019. The Objective Structured Assessments of Technical Skills (OSATS) scoring system was used to grade videos from the ICG and non-ICG groups. Patients with an OSATS score greater than 29 were classified as the high-OSATS population, while those with an OSATS score less than or equal to 29 were classified as the low-OSATS population.

RESULTS

A total of 258 patients were included in the modified intention-to-treat analysis: 129 in the ICG group and 129 in the non-ICG group. The OSATS score of the ICG group was higher than that of the non-ICG group (29.6±2.6 vs. 26.6±3.6; P <0.001). The ICG group underwent a significantly higher mean total number of lymph node dissections than the non-ICG group (50.5±15.9 vs. 42.0±10.3; adjusted P <0.001). The group assigned to ICG use, better OSATS (high-OSATS) scores were observed, which correlated with greater D2 lymph node retrieval (54.1±15.0 vs. 47.2±8.7; adjusted P =0.039). Finally, the ICG group had a lower rate of lymph node noncompliance than that of the non-ICG group (31.8 vs. 57.4%; P <0.001).

CONCLUSIONS

By applying the ICG fluorescence navigation technique, better OSATS scores were observed, which correlated with greater lymph node retrieval and a lower lymph node noncompliance rate, as recommended for individualized laparoscopic radical gastrectomy.

[Indocyanine green angiography in assessment of parathyroid remnant perfusion after subtotal parathyroidectomy: a case report]

A 72-year-old female patient with chronic kidney disease stage presented with multiple parathyroid adenomas and tertiary hyperparathyroidism. SPECT/CT with 99mTc-MIBI revealed accumulation of radiopharmaceuticals in 2 out of 4 parathyroid glands. Ultrasound established localization of all parathyroid glands. Subtotal parathyroidectomy with excision of 3 glands and resection of half of the fourth gland was performed. Intraoperative indocyanine green angiography was performed to identify all parathyroid glands and remnant perfusion. There was normal parathyroid function after 6 months.

[Indocyanine green in delayed esophageal reconstruction after previous extirpation]

Advanced chemo- and radiotherapy makes it possible to expand the cohort of patients who can undergo surgical treatment for esophageal cancer. Optimization of perioperative approach, diagnosis and modern options for complications reduced early postoperative mortality after esophagectomy. Conduit ischemia with failure of esophageal-gastric or esophageal-intestinal anastomosis is one of the most serious complications. To minimize the risk of anastomotic leakage and graft necrosis in these patients, various methods of intraoperative assessment of graft viability are being investigated. Near-infrared fluorescence imaging with indocyanine green is valuable for real time assessment of graft perfusion. To date, fluorescence imaging is analyzed regarding perfusion of the gastric stalk after esophagectomy. However, there are still few or no data on this method for analysis of colonic conduit perfusion. The absence of plastic material for gastrointestinal reconstruction is the most dangerous moment in case of ischemia and necrosis of colonic graft. We present our first case of delayed retrosternal esophageal repair using intraoperative indocyanine green fluorescence imaging for assessment of conduit perfusion.

[Indocyanine green fluorescence in thoracoscopic segmentectomy: indications and benefits]

OBJECTIVE

To determine the role of ICG fluorescence in segmentectomies.

MATERIAL AND METHODS

One surgical team performed 178 thoracoscopic anatomical segmentectomies in two hospitals between 2017 and 2023. Of these, 93 (52.2%) patients underwent ICG fluorescence perfusion tests. This study was retrospective and consecutive. Intraoperative and early postoperative results were analyzed. Patients were divided into 3 equal periods. Ventilation and perfusion methods were used to navigate the intersegmental planes in the first period. In the second one, only ventilation methods were used due to the absence of ICG. In the third period, the choice of navigation method was determined by «surgical complexity of segment».

RESULTS

In 74% of patients, surgeries were performed for primary or metastatic lung tumors. The scheduled procedure was performed in all patients. However, 2 ones required lobectomy for total resection. Uneventful postoperative period was observed in 69.7% of patients. Other ones had complications grade I-IIIA. No reoperations or mortality were recorded.

CONCLUSION

ICG perfusion is not inferior to ventilation methods in identification of intersegmental planes. This method is also more convenient for thoracoscopy. ICG fluorescence thoracoscopy is the only method in patients with COPD scheduled for thoracoscopic segmentectomy with two or more intersegmental planes.

[Domestic system for fluorescent diagnostics in breast cancer: pros and cons]

OBJECTIVE

To analyze the effectiveness of identifying the sentinel lymph node in breast cancer using the «MARS» system for fluorescent diagnostics in near infrared light.

MATERIAL AND METHODS

There were 51 patients with breast cancer cT0-2N0M0 between July 2023 and October 2023. Mean age of patients was 52.3 years. Invasive ductal carcinoma was diagnosed in 39 (76.5%) patients, invasive lobular carcinoma - in 8 (15.7%) patients, other forms of breast cancer - in 4 (7.8%) patients.

RESULTS

Sentinel lymph node was successfully identified in all cases (n=51). A total of 122 sentinel lymph nodes were detected and mapped (2.4 nodes per a patient).

CONCLUSION

The MARS system for intraoperative fluorescence diagnostics in near-infrared light is effective for identifying the sentinel lymph node in breast cancer.

Sentinel lymph node biopsy for head and neck malignancies utilizing simultaneous radioisotope gamma probe and indocyanine green fluorescence navigation

We depict an innovative surgical approach for sentinel lymph node biopsy (SLNB) in head and neck malignancies that utilizes both near-infrared (NIR) imaging with indocyanine green (ICG) dye and hand-held gamma probe intraoperatively to isolate and excise SLNs. Twenty-one patients presented to our institution with cutaneous melanoma, cutaneous squamous cell carcinoma (SCC), and oral cavity SCC tumors that met criteria for SLNB based on tumor depth and histology. The video offers a step-by-step approach for this technique along with descriptions of recommended equipment. Among 21 patients, two patients had positive SLNs on final pathology. One patient developed a local recurrence over an average of 16.2 months of follow-up (SD = 15.6). SLNB with ICG and radionucleotide co-localization may enhance the identification of sentinel nodes without compromising outcomes in the hands of surgeons well-versed in the technique.

[Intraoperative near-infrared fluorescence imaging of peripheral lung tumors]

The main objective of surgical intervention in lung cancer is the radical removal of the entire tumor with the maximum possible preservation of healthy tissue. Although the area of the tumor lesion is known by the results of preoperative studies, it can be difficult to use this information to establish the exact boundaries of resection during surgery, especially with small sizes of the lump and when using minimally invasive approaches. There are several techniques to solve this problem. One of the latter is intraoperative fluorescence imaging in the infrared range, which makes it possible to detect a tumor not only with greater contrast than it can be done in white light, but also with its deep location. This review is devoted to the discussion of various aspects of this approach related to molecular imaging methods. The current situation based on the use of green indocyanine green, available for clinical use as a fluorescent agent is considered, the issues of using new targeted drugs are examined, as well as the possibility of increasing the depth of probing and combining with related treatment methods, which should contribute to a more radical operation and reduce the likelihood of local relapses.

[Fluorescence lymphoscopy with sentinel lymph node biopsy in research of lymphatic flow in early gastric cancer]

OBJECTIVE

To analyze the incidence and risk factors of regional lymph node metastatic lesions, as well as patterns of lymphatic drainage in early gastric cancer using indocyanine green (ICG).

MATERIAL AND METHODS

A prospective single-center non-randomized study included 67 patients with early gastric cancer between 2016 and 2019. All patients underwent endoscopic dissection or surgical resection with sentinel lymph node biopsy.

RESULTS

Regional lymph node metastatic lesions were detected in 12 (20.2%) out of 59 patients with examined lymph nodes. Of these, 11 out of 12 patients had sentinel lymph node lesion, and only 1 patient had metastasis outside this lymph node. The proposed technique for sentinel lymph node biopsy demonstrated high sensitivity, specificity and accuracy (93.2%, 100% and 98.3%, respectively). Risk factors for metastasis of early gastric cancer to regional lymph nodes were high grade adenocarcinoma (p=0.038) and tumor of anterior gastric wall (p=0.013). All patients with tumors of the upper third of the stomach had sentinel lymph node in the left gastric artery basin. Lymph flow was multidirectional in patients with tumors of the middle third of the stomach. In tumors of the lower third of the stomach, sentinel lymph node was located in the right gastroepiploic artery (50%) and left gastric artery basins (36.84%) (p=0.002). Sentinel lymph node was located in the left gastric artery basin in 84% of patients with tumors of the lesser curvature (p<0.001). Lymphatic drainage was multidirectional if tumors were localized on anterior and posterior walls, as well as on the greater curvature.

CONCLUSION

The proposed technique for sentinel lymph node biopsy demonstrated high sensitivity, specificity and accuracy (93.2%, 100% and 98.3%, respectively). ICG is valuable to identify the first lymph node in lymphatic drainage pathway in 83.6% of cases that makes it possible to assess the regional lymphatic collector. In addition, sentinel lymph node biopsy with ICG contributes to analysis of lymphatic drainage in early gastric cancer. The last one has both scientific and practical significance.

Efficacy and outcome of indocyanine green-based intraoperative cholangiography using near-infrared fluorescence imaging: A prospective study

INTRODUCTION

The most dreaded complication during laparoscopic cholecystectomy still remains to be injury to the common bile duct. The primary cause for bile duct injury during LC is misinterpretation of the biliary anatomy. Intra-operative cholangiography was introduced as a means of reducing the chances of biliary injury, done using Fluoroscopic imaging or Near-infrared fluorescence imaging method. NIRF is one of the most popular imaging methods in biomedical sciences. Indocyanine Green is sterile and water soluble which completely binds to albumin and is excreted in bile.

PATIENTS AND METHODS

This prospective study was conducted among 70 patients between July 2020 and December 2021. Subjects were administered 5mg of ICG dye pre-operatively and procedure performed using Karl Storz HD image S1 system with a D-light P light source for NIRF imaging.

RESULTS

The average duration of surgery was 58.10 minutes. After calot's dissection, the CBD was visualized in 88.71 % patients, with a mean time to visualization at 26.33 minutes. The cystic duct was visualized in 87.3% cases with a mean time of visualization of 32.10 minutes. The hepatic duct was visualized in 28.57% and the hepatic duct-CBD confluence was visualized in 34.28% patients.

CONCLUSION

Near infrared imaging based intra-operative cholangiography, using Indocyanine Green dye, during Lap. Cholecystectomy is an easy, useful and inexpensive method of visualizing the biliary ductal anatomy.

Real-time visualization of skeletal muscle necrosis in mice and swine through NIR-II/I fluorescence imaging

Avulsion often occurs in the limb due to heavy shearing forces which not only damage skeletal muscle but also main vessels, resulting in life-threatening muscle ischemia and necrosis. Defining muscle activity is vital for surgical repair. Currently, the color, capacity of blood, contractibility, and consistency (4C) are the primary principles for evaluating the activities of torn muscles. Based on clinical experiences, this standard turns out to be delayed diagnosis, which is not defined by specific parameters. Recently, near-infrared (NIR) fluorescence probes emitting within the second near-infrared window (NIR-II, 1000-1700 nm) have been widely used for non-invasive optical imaging because the tissue absorption and autofluorescence in the NIR-II region are negligible, thus allowing deeper penetration depths with micrometer-scale spatial resolution in vivo. As pathogenesis and development of muscle necrosis, necrosis-related protein may participate in this procedure. There is promising future for NIR-II to be used in evaluating muscle activity in avulsion. A new approach is developed based on experiments with mice and large animals (swine). Myoblasts were incubated with indocyanine green (ICG) to identify the necrosis muscles. The model of extremity damaged muscle was established for the real-time visualization and detection of developed necrosis muscle field under new equipment, both in balb/c mice (female) and long-haired swines. A visible NIR-II/I imaging system was first used in a large animal injured skeletal muscle-related model. Our NIR-II/I imaging system is suitable for evaluating the normal and injured skeletal muscle ICG cycle and pointing to the necrotic skeletal muscle tissue. NIR-II imaging is superior to NIR-I imaging in estimating skeletal muscle, best with 1100 nm filter. NIR-II fluorescence with 1100 nm filter is suitable for analyzing the progress of necrosis muscle tissue, leading to a new approach for intraoperative evaluation.

[Fluorescence navigation and angiography with indocyanine green in stomach cancer surgery]

OBJECTIVE

To evaluate the effectiveness of intraoperative angiography and fluorescence navigation with indocyanine green in reducing the risks of intra- and postoperative complications, as well as resection quality in patients with gastric cancer.

MATERIAL AND METHODS

The main group consisted of patients who underwent intraoperative angiography and fluorescence navigation with indocyanine green (n=43). The control group included patients without these procedures (n=154). Both groups did not differ in gender (p=0.937) and age (p=0.437). The lower third of the stomach was the most common tumor location in the main group (62.7% of cases), the middle and lower thirds of the stomach - in the control group (37% and 38.9% of patients, respectively). There was no between-group difference in «cT» grading (p>0.05). However, there were more «cN+» patients in the main group (14 (32.6%) versus 28 (18.4%) ones of «N0» category, p=0.042). Therefore, 41.9% and 13.6% of patients underwent neoadjuvant chemotherapy in both groups, respectively (<0.001).

RESULTS

Intraoperative angiography and fluorescence navigation with indocyanine green does not increase mortality (p=0.631), incidence of major (CD 3-5) (p=0.436) and minor (CD 1-2) postoperative complications (p=0.177), surgery time (p=0.288), mean intraoperative blood loss (p=0.144) and length of hospital-stay (p=0.631). Fluorescence navigation with indocyanine green does not affect the number of detected «positive» resection margins (R1) (p=0.883) but significantly increases the number of excised lymph nodes (p<0.001).

CONCLUSION

Intraoperative angiography and fluorescence navigation with indocyanine green are safe for intraoperative visualization of tumor and lymph nodes, as well as assessment of arterial blood supply. This technique is effective in traditional and minimally invasive surgeries for gastric cancer. Fluorescence navigation with indocyanine green significantly increases the number of excised lymph nodes.

[Fluorescence lymphography for sentinal lymph node biopsy in breast cancer]

OBJECTIVE

To study diagnostic value of fluorescence lymphography for sentinel lymph node biopsy in breast cancer.

MATERIAL AND METHODS

The study enrolled 25 patients with breast cancer T1-2N0-1M0 between March 2023 and July 2023. Eight ones underwent neoadjuvant chemotherapy. In 3 patients, morphologically verified metastases cN1 in axillary lymph nodes regressed after treatment. After sentinel lymph node biopsy, all patients underwent standard axillary lymphadenectomy. Subareolar injection of indocyanine green 1 ml (5 mg/ml) was performed immediately before surgery. Fluorescence imaging was performed using the MARS system.

RESULTS

Detection rate was 100%. Mean number of sentinel lymph nodes was 2. Metastatic lesions of sentinel lymph nodes were observed in 6 patients (24%) with micro-metastases in 2 cases. In 50% of cases, metastatic lesion did not extend beyond sentinel lymph nodes. False negative result was obtained in 1 (4%) patient. Mean number of metastases was 1.8 (max 3 in one patient).

CONCLUSION

Sentinel lymph node biopsy with fluorescence lymphography is a sensitive method. The advantages of this technique are visualization of subcutaneous lymphatic vessels and skin incision for access to sentinel lymph nodes, as well as visualization of sentinel lymph nodes after skin incision.

[First experience of applying domestic video fluorescent equipment for visualization and blood flow evaluation of the parathyroid glands]

In recent years, predictive methods for assessing the preservation of the parathyroid glands have been actively implemented. The article describes the first experience of evaluating the blood supply of the parathyroid glands by quantitative determination of the indocyanine green (ICG) accumulation index in real time in 6 patients before and after a thyroidectomy with central neck lymph node dissection for papillary thyroid cancer. Intraoperative fluorescent angiography was performed by using domestic equipment with a fluorescent module, as well as by using a domestic medication of ICG. Intraoperative values of the ICG accumulation index were compared with the levels of ionized calcium and parathyroid hormone perioperatively. No clinical manifestations of hypocalcemia were detected in the postoperative period. The obtained results showed the informativeness of the numerical assessment of the intensity of ICG fluorescence. The evaluation of the distribution (accumulation) of ICG has prospects for practical application in thyroid surgery in the formation of tactics for preserving the parathyroid glands and predicting postoperative hypoparathyreosis.

Indocyanine green and iohexol loaded hydroxyapatite in poly(L-lactide-co-caprolactone)-based composite for bimodal near-infrared fluorescence- and X-ray-based imaging

This study aimed to develop material for multimodal imaging by means of X-ray and near-infrared containing FDA- and EMA-approved iohexol and indocyanine green (ICG). The mentioned contrast agents (CAs) are hydrophilic and amphiphilic, respectively, which creates difficulties in fabrication of functional polymeric composites for fiducial markers (FMs) with usage thereof. Therefore, this study exploited for the first time the possibility of enhancing the radiopacity and introduction of the NIR fluorescence of FMs by adsorption of the CAs on hydroxyapatite (HAp) nanoparticles. The particles were embedded in the poly(L-lactide-co-caprolactone) (P[LAcoCL]) matrix resulting in the composite material for bimodal near-infrared fluorescence- and X-ray-based imaging. The applied method of material preparation provided homogenous distribution of both CAs with high iohexol loading efficiency and improved fluorescence signal due to hindered ICG aggregation. The material possessed profound contrasting properties for both imaging modalities. Its stability was evaluated during in vitro experiments in phosphate-buffered saline (PBS) and foetal bovine serum (FBS) solutions. The addition of HAp nanoparticles had significant effect on the fluorescence signal. The X-ray radiopacity was stable within minimum 11 weeks, even though the addition of ICG contributed to a faster release of iohexol. The stiffness of the material was not affected by iohexol or ICG, but incorporation of HAp nanoparticles elevated the values of bending modulus by approximately 70%. Moreover, the performed cell study revealed that all tested materials were not cytotoxic. Thus, the developed material can be successfully used for fabrication of FMs.

[Analysis of indocyanine green plasma disappearance rate in clinical practice]

OBJECTIVE

To justify the optimal method for determining indocyanine green plasma disappearance rate (PDRICG).

MATERIAL AND METHODS

We analyzed PDRICG in intensive care units. Indocyanine green was administered intravenously at a dose of 0.25 mg/kg. PDRICG was analyzed simultaneously by using of three methods: 1) PDD (PiCCO2 LiMON device), 2) SBS with analysis of plasma samples on precise spectrophotometer, 3) SBS with analysis of plasma samples on simple experimental photometer.

RESULTS

PDD method was used for 346 PDRICG tests in 256 patients. Of these, 14.3% of measurements were erroneous. Paired tests using PDD and SBS methods were performed in 299 cases. SBS method resulted erroneous data in 0.6% of cases. Certain correlation (r=0.79, p<0.001) was found between the reference method (SBS with spectrophotometry) and the PDD method. Bland-Altman plot for these two methods showed that proportional bias of mean difference was caused by extremely high PDRICG of the PDD method (for example, more than 30%/min). Comparison of two SBS variants (spectrophotometer and experimental photometer) revealed good correlation (r=0.91, p<0.001).

CONCLUSION

SBS method for measuring PDRICG ensures accurate results under mechanical interferences in patients with impaired capillary blood flow. This eliminates the need for redo measurement. Duplication of the PDD and SBS methods is recommended when repeating the test is not possible (organ donors).

First experience]

OBJECTIVE

To assess the possibilities of fluorescent detection system in qualitative and quantitative assessment of bowel perfusion in colorectal resections.

MATERIAL AND METHODS

From May to August 2023, a single-center pilot cross-sectional unblinded study with inclusion of 18 patients with colon cancer (of left-sided - 12, of right-sided - 6, mean age - 72.9 years, m/w - 61/39%) was conducted. All patients underwent laparoscopic colorectal resections with extracorporeal stage of bowel transection. The evaluation of the bowel's ICG perfusion was conducted to assist in decision making about the level of its resection. Qualitative (visual) assessment was carried out in all 18 patients, in one patient twice, quantitative assessment of perfusion was conducted in 8 patients (left-sided resections - 6, right-sided hemicolectomy - 2). The qualitative evaluation was performed in real time on the analysis of the color gradient. The time parameters and fluorescence intensity at different level proximally and distally from the resection line were quantitatively estimated: Tstart - time of occurrence of minimal fluorescence in the areas of interest after the ICG injection (sec); Tmax - time to achieve maximum fluorescence intensity after the ICG injection (sec); Tmax-start - time interval between Tstart and Tmax, Imax - level of maximum fluorescence intensity (I).

RESULTS

Visual qualitative analysis of fluorescence revealed unsatisfactory perfusion characteristics (black, dark-gray color) in the area planned by the surgeon to anastomose the bowel in 3 of 18 patients (16.6%). When analyzing the quantitative data of this group of patients, there was a 2-6-fold decrease in Imax level, and one patient had an increase in Tmax-start at the level of intended resection compared to the bowel's sections in the favorable zone. In all cases, the final bowel transection was conducted in the area of good perfusion. There was no clinical evidence of anastomotic dehiscence in the study group.

CONCLUSION

Intraoperative evaluation of bowel perfusion is an important component of safe anastomosis formation in colorectal surgery. The use of ICG-FA allows to conduct qualitative and quantitative assessment of tissue perfusion of the bowel in order to assist in making intraoperative decisions. Quantitative evaluation of fluorescence provides more objective information about perfusion parameters. Imax and Tmax-start are the most promising quantitative indicators of local bowel's perfusion. Nevertheless, the precise interpretation of the quantitative indicators of ICG perfusion needs to be clarified.

Right hemihepatectomy preserving the fluorescently visible paracaval portion of the caudate lobe

The paracaval portion (PC) of the caudate lobe is a small area of the liver located in front of the inferior vena cava. Conventional right hemihepatectomy (RH) along the Rex-Cantlie line involves resection of not only the anterior and posterior sections but also the PC behind the middle hepatic vein (MHV). However, to preserve the future liver remnant volume as much as possible, PC-preserving RH may be beneficial in selected patients. We injected an indocyanine green (ICG) solution in the PC portal branch under intraoperative ultrasonography (IOUS) guidance and performed an RH preserving the fluorescently visible PC in a patient with liver metastasis. The patient was a 47-year-old male with a 24 ×10 cm metastatic hepatic tumor from sigmoid colon cancer. CT volumetry revealed that the left hemiliver excluding the caudate lobe was 55%, and the caudate lobe was 5.3%. Before hepatic transection, the ICG solution was injected into the PC portal branch under IOUS guidance. During hepatic transection, the PC was identified as a fluorescent area behind the MHV using a near-infrared imaging system. Thus, the anatomical right-side boundary of the caudate lobe was clearly found. Following RH, the PC was preserved as a fluorescently visible area. The patient had an uneventful recovery. RH preserving the fluorescently visible PC of the liver is a feasible procedure.

Indocyanine Green-Loaded Liposomes-Assisted Photoacoustic Computed Tomography for Evaluating In Vivo Tumor Penetration of Liposomal Nanocarriers

Liposomes possess the potential to enhance drug solubility, prolong the duration of circulation, and augment drug accumulation at the tumor site through passive and active targeting strategies. However, there is a lack of studies examining the in vivo tumor penetration capabilities of liposomes of varying sizes, which hampers the development of drug delivery systems utilizing liposomal nanocarriers. Here, we present an indocyanine green (ICG)-loaded liposomes-assisted photoacoustic computed tomography (PACT) for directly evaluating the tumor penetration ability of liposomal nanocarriers in vivo. Through the utilization of microfluidic mixing combined with extrusion techniques, we successfully prepare liposomes encapsulating ICG in both large (192.6 ± 8.0 nm) and small (61.9 ± 0.6 nm) sizes. Subsequently, we designed a dual-wavelength PACT system to directly monitor the in vivo tumor penetration of large- and small-size ICG-encapsulated liposomes. In vivo PACT experiments indicate that ICG-loaded liposomes of smaller size exhibit enhanced penetration capability within tumor tissues. Our work presents a valuable approach to directly assess the penetration ability of liposomal nanocarriers in vivo, thereby facilitating the advancement of drug delivery systems with enhanced tumor penetration and therapeutic efficacy.