Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary

BACKGROUND

Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery.

METHODS

A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model.

RESULTS

From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature.

CONCLUSION

The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

Fluorescence-guided lymphadenectomy in gastric cancer: a prospective western series

BACKGROUND

Indocyanine green (ICG) has been recently introduced in clinical practice as a fluorescent tracer. Lymphadenectomy is particularly challenging in gastric cancer surgery, owing to the complex anatomical drainage.

AIM

The primary outcomes of this study were the feasibility and usefulness of ICG-guided lymphadenectomy in gastric cancer surgery, considering both the success rate and improved understanding of the surgical anatomy of nodal basins. The secondary outcome was the diagnostic ability of ICG to predict the presence of nodal metastases.

PATIENTS AND METHODS

We conducted a single-center prospective trial comprising 13 patients with gastric cancer. ICG was injected the afternoon prior to surgery or intraoperatively via the submucosal or subserosal route. Standard lymphadenectomy was performed in all patients, according to patient age and tumor stage, as usual, but after standard lymphadenectomy the residual ICG + nodes were harvested and analyzed. Each nodal station and each dissected node was recorded and classified as ICG + or ICG- (both in vivo and back table evaluation was utilized for classification). After pathological analysis, each nodal station and each dissected node was recorded as metastatic or nonmetastatic (E&E staining).

RESULTS

The feasibility rate was 84.6% (11/13). The mean number of dissected lymph nodes per patient was 37.9. Focusing on the 11 patients in whom ICG-guided nodal navigation was successfully performed, 81 lymph node stations were removed, for a total of 417 lymph nodes. Sixty-six stations (81.48%), comprising a total of 336 lymph nodes, exhibited fluorescence. No IC- node was metastatic; all 54 metastatic nodes were ICG + . A total of 282 ICG + nodes were nonmetastatic. In two cases, some nodes outside D2 areas were harvested, being ICG + (1 case of metastatic node).

CONCLUSIONS

Fluorescence lymphography-guided lymphadenectomy is a promising new technique that combines a high feasibility rate with considerable ease of use. Regarding its diagnostic value, the key finding from this prospective series is that no metastatic nodes were found outside fluorescent lymph node stations. Further studies are needed to investigate whether this technique can help surgeons performing standard lymphadenectomy and selecting cases for D2 + lymphadenectomy.

Stage IV Gastric Cancer: The Surgical Perspective of the Italian Research Group on Gastric Cancer

Background/Aim: This work explored the prognostic role of curative versus non-curative surgery, the prognostic value of the various localizations of metastatic disease, and the possibility of identifying patients to be submitted to aggressive therapies. Patients and Methods: Retrospective chart review of stage IV patients operated on in our institutions. Results: Two hundred and eighty-two patients were considered; 73.4% had a single metastatic presentation. In 117 cases, a curative (R0) resection of primary and metastases was possible; 75 received a R1 resection and 90 a palliative R2 gastrectomy. Surgery was integrated with chemotherapy in multiple forms: conversion therapy, HIPEC, neo-adjuvant and adjuvant treatment. Median overall survival (OS) of the entire cohort was 10.9 months, with 14 months for the R0 subgroup. There was no correlation between metastasis site and survival. At multivariate analysis, several variables associated with the lymphatic sphere showed prognostic value, as well as tumor histology and the curativity of the surgical procedure, with a worse prognosis associated with a low number of resected nodes, D1 lymphectomy, pN3, non-intestinal histology, and R+ surgery. Considering the subgroup of R0 patients, the variables pT, pN and D displayed an independent prognostic role with a cumulative effect, showing that patients with no more than 1 risk factor can reach a median survival of 33 months. Conclusions: Our data show that the possibility of effective care also exists for Western patients with stage IV gastric cancer.

Intraoperative ICG-based imaging of liver neoplasms: a simple yet powerful tool. Preliminary results

BACKGROUND

Detecting small nodules that are grossly unidentifiable remains a major challenge in liver resection for cancer. Novel developments in navigation surgery, especially indocyanine green (ICG)-based fluorescence imaging, are making a clear breakthrough in addressing this issue. ICG is almost routinely administered during the preoperative stage in hepatobiliary surgery. However, its full potential has yet to be realized, partly because there are no precise guidelines regarding the optimal dose or timing of ICG injections before liver surgery. The main goal of this study was to design an algorithm for the management of ICG injections to achieve optimal liver staining results.

METHODS

Twenty-seven consecutive, unselected patients undergoing liver resection for cancer were enrolled and underwent preoperative liver function assessment by the LiMON test. Extra ICG i.v. injections at different doses and timings were performed. In vivo intraoperative analysis of the stain detected by near-infrared fluorescence imaging of the liver and ex vivo analysis of each resected nodule was performed and compared to the pathological analysis.

RESULTS

(i) The success rate of ICG injections in terms of liver staining was 92.6%; (ii) in the absence of or with 7 or more days from a previous ICG injection, the best dose to inject before the operation was 0.2 mg/kg, and the best timing was between 24 and 48 h before the scheduled surgery; and (iii) the ICG fluorescence patterns observed in the tumors were total fluorescence staining (41% of the cases), partial fluorescence staining (15%), rim fluorescence staining surrounding the tumor (30%), and no staining (15%).

CONCLUSIONS

This study is a building block for the characterization of liver nodules and the search for additional surface lesions undetected by preoperative radiological work-up-a crucial task for the successful treatment of liver cancer at an early stage using a safe, minimally invasive, and inexpensive technique.

Gastric cancer indocyanine green lymph node navigation surgery: systematic review

Sentinel lymph node (LN) biopsy is a common practice to determinate if a lymphadenectomy is needed in various malignancies. Recent studies have investigated the possibilities to extend sentinel LN biopsy in gastric cancer. Indocyanine green (ICG) is a diagnostic reagent recently introduce in sentinel LN biopsy field. This review aims to determinate the feasibility to used ICG to detect sentinel LN in gastric cancer.

Different ways to manage indocyanine green fluorescence to different purposes in liver surgery: A systematic review

Fluorescent properties of indocyanine green (ICG) for hepatic tumor identification and features have been recently studied. The aim is to review the published data on the use of ICG enhanced fluorescence surgery during liver resection. A systematic search of literature was performed using MEDLINE, EMBASE, Cochrane and Web of Science libraries. For all eligible studies, the following data were extracted: study design, number of cases, management of indocyanine green (dose, time and method of administration), type of surgery, outcome variables, false positive and accuracy value, if reported. For statistical analysis, it was considered significant P<0.05, when published. 19 articles were fully analyzed and data were extracted. A total of 718 cases were globally analyzed as study group. No side effects of ICG were reported in any articles. 12 prospective observational, 1 randomized and 2 case-control studies were found. Three case reports and one experimental on animal model were also included. Detection of superficial lesions, segmental staining, biliary anatomy investigation (biliary leakage detection, biliary tree anatomy) were the main clinical application of fluorescence liver guided surgery. The overall quality of the data currently available is limited but the role of fluorescence guided liver surgery seems promising.

Indocyanine-Green Fluorescence-GUIDED Liver Resection of Metastasis from Squamous Cell Carcinoma Invading the Biliary Tree

Background. The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) is a developing interest in many fields of surgical oncology. The technique seems to be promising also during hepatic resection. Case Presentation. We reported our experience of ICG-fluorescence-guided liver resection of metastasis located at VIII Couinaud's segment from colon squamous cell carcinoma of a 74-year-old male patient. Results. After laparotomy, the fluorescing tumour has been clearly identified on the liver surface. We have also identified that a large area of fluorescent parenchyma that gets from the peripheral of the lesion up to the portal pedicle such as the neoplasia would interest the right biliary tree in the form of neoplastic lymphangitis. This datum was not preoperatively known. Conclusion. Fluorescent imaging navigation liver resection could be a feasible and safe technique helpful in identifying additional characteristics of lesion. It could be a powerful tool but further studies are required.

How could we identify the 'old' patient in gastric cancer surgery? A single centre cohort study

PURPOSE

To analyze the population submitted to gastric cancer surgery in our Institution in order to find those characteristics which could help in the identification of the elderly high-risk patient.

METHODS

In a cohort of 263 patients (>65 y) we selectively investigated the risk factors for medical and surgical complications and postoperative mortality, focusing on the variable "age". All the significant variables were used to find predictors of complications with Clavien-Dindo>2.

RESULTS

Age>75 (AUC 0.61; 95% 0.55-0.67, p = 0.003) and ASA score >2 (AUC 0.60; 95% CI 0.54-0.67, p = 0.01) were significantly associated with an increased risk of medical complications. Operative time >330 min (OR 1.00; 95% CI 1.00-1.01; p = 0.0001- AUC 0.62, 95% CI 0.56-0.68, p = 0.01) was the only significant predictor of surgical complications. In-hospital mortality (6/263 patients) was significantly associated with preoperative albumin ≤2.95 g/dl (OR 0.15; 95% CI 0.04-0.93, p = 0.041 - AUC 0.74 95% CI 0.68-0.80; p = 0.003) and additional procedures (OR 7.05; 1.23-40.32, p = 0.03). Stepwise multivariate analysis showed that albumin ≤2.95 g/dl (OR 3.43; 95% CI 1.06-11.13 p = 0.033), ASA>2 (OR 9.51; 95% CI 1.23-72.97; p = 0.042) and additional resections (OR 3.39; 95% CI 1.36-8.45; p = 0.045) were independent risk factors for complications Clavien Dindo >2.

CONCLUSIONS

Our work demonstrated that, in our institution, 75 years of age could identify the elderly in gastric surgery as those patients were at higher risk of medical complications. ASA >2, preoperative serum albumin ≤2.95 g/dl and the need of additional procedures could increase the risk of severe postoperative adverse events.

Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?

Laparoscopic cholecystectomy entails an increased risk of gallbladder rupture and consequent loss of stones in the abdominal cavity. Herein we report the case of a 51-year-old male patient, who underwent laparoscopic cholecystectomy 2 years before presentation to our hospital. He had experienced tension sensation and epigastric pain since 4 months postoperatively. A well-defined epigastric mass, which was hard and painful on palpation, was detected and later confirmed by ultrasonography and CT scan. Explorative laparotomy revealed a mass in the area of the gastrocolic ligament,resulting from biliary gallstones in conjunction with a perimetral inflammatory reaction. A review of the literature showed that the incidence of gallbladder lesions during laparoscopy is 13-40%. In order to prevent this complication, meticulous isolation of the gallbladder, proper dissection of the cystic duct and artery, and careful extraction through the umbilical access are required. Ligation after the rupture or use of an endo-bag may be helpful. The loss of gallstones and their retention in the abdominal cavity should be noted in the description of the surgical procedure.

Description of new "bowel-sparing" techniques for long strictures of Crohn's disease

In the period of January 1993 to December 1995 we operated on 55 patients with various complications of Crohn's disease. In properly selected cases, obstructive complications of Crohn's disease can be treated effectively by strictureplasty. Long strictures, even if a narrow lumen is still present, are commonly managed by resection, as classic strictureplasties cannot be done; also Finney strictureplasty seems inadequate, as it creates a blind loop that favors bacterial overgrowth and fecal stasis. Three original "sparing bowel" surgical approaches are proposed as possible alternative in the treatment of long stricture in Crohn's disease. We perform side-to-side ileoileal plasty whenever we are faced with severe narrowing of a long segment of small bowel (>10 cm); side-to-side ileocolic plasty whenever very severe disease with narrowing of ileocaecal valve is present; and ileocaecal plasty when terminal ileitis involves the very distal end of the small bowel, but sparing or only minimally affecting the ileocaecal valve. The above-mentioned procedures are described in detail and the clinical outcomes related to the first 8-patient series of our institution are presented.

[Validity, limitations and indications of intraoperative dosage of parathyroid hormone (I-PTH) in the surgical treatment of primary hyperparathyroidism]

INTRODUCTION

Recently new methods have been experienced to achieve the best surgical results in complete removal of pathological parathyroid tissue; serum I-PTH (1-84) rapid dosage is the most interesting and reliable method.

MATERIAL AND METHODS

In a group of 11 patients with IPP, diagnosed by high levels of I-PTH, total and ionized serum calcium, 7 were paucisymptomatic, 3 presented nephrolityasis, 1 acute pancreatitis and severe hypercalcemic crisis. No MEN were found. A systemic research of all parathyroid glands was always performed, then 10, 20, 30 and any 30 minutes after each parathyroidectomy serum I-PTH rapid dosage was made (rapid IRMA method) until the end of surgical treatment.

RESULTS

Eight single adenomas parathyroid were diagnosed, 1 double adenoma and 2 hyperplasia. All patients had high levels of serum I-PTH during pathologic parathyroid removal. The decrement of I-PTH level to 40% 10 min after parathyroidectomy, and 50% after 20 minutes confirmed the efficacy of surgery.

DISCUSSION

Intraoperative rapid dosage of I-PTH associated with anatomopathologic results leads to a successful diagnosis and therapy. Sometimes in multiglandular disease serum level of PTH decreases after first parathyroidectomy as in a single adenoma: this underlines the importance of systematic surgical research of all glands in any case.

CONCLUSION

In our experience serum I-PTH rapid dosage in IPP would be applied by specialized surgical equipments only in selected patients, such as reoperation or those few cases of first surgical treatment when ectopy is suspected.

Surgical treatment and prognostic variables of hepatocellular carcinoma in 122 cirrhotics

A 10-year experience in surgical treatment of HCC in 122 cirrhotic patients has been reviewed in order to evaluate: perioperative mortality and morbidity, survival rates and prognostic variables by multiple-logistic analysis. Mortality rate declined from 7% in period 1983-88 to 2% in period 1989-92. Operative complications also decreased from 46% to 30%. The 3-year and 5-year overall survival rates were 42.6% and 23.3%. The 3-year and 5-year survival of patients who died only for HCC was 51.1% and 34.2% and the disease-free survival 30.6% and 19.1%. The good results of overall survival were vanished by the high rate of recurrence (19.1%). Multiple logistic regression analysis for the probability of mortality was significant for satellite nodules (RR 2.437), microvascular infiltration (RR 2.432), tumor size (RR 1.147); the model for the probability of recurrence was significant for microvascular infiltration (RR 2.290), satellite nodules (RR 2.280), lesions number (RR 2.216) and tumor size (RR 1.247).

Linguistic development in a patient with Landau-Kleffner syndrome: a nine-year follow-up

A longitudinal linguistic analysis of aphasic disorder in a 15-year-old boy affected by Landau-Kleffner syndrome followed since the age of 6 is reported. The phonological, morphosyntactic and lexical levels of verbal deficits have been evaluated by means of collected samples of spontaneous language and a battery of linguistic tests. The clinical course has fluctuated with improvement and worsening of aphasia and epilepsy; at the end of the follow-up the boy was seizure-free and a medium-degree disturbance in language production and comprehension was present. The results of the linguistic evaluation suggest that the aphasic disturbance was related to a deficiency in phonological decoding which leads to phonological, morphosyntactic and lexical disturbances. A temporal relationship between the electroclinical picture and the aphasia has been observed: the persistent improvement in linguistic performances took place only after the disappearance of the seizures and of the EEG epileptic anomalies during sleep.

[Ciclopiroxolamine in the topical treatment of vaginal mycoses]

We have verified the local activity and tolerance of the antimycotic drug ciclopiroxolamine in an open trial. The study included 34 women suffering from clinically and mycologically diagnosed vulvovaginitis caused by Candida. The therapy consisted of inserting a 100 mg ovule of ciclopiroxolamine once a day for 3 days. The cultural examination was negative in 76.5% of cases at the 1st control after the treatment and in 82.3% of cases at the 2nd control after the treatment. All the considered subjective and objective symptoms showed a highly significant decrease of frequency and intensity. No chemical parameter was modified; only in one patient a very mild side effect was verified.

Relation between CT patterns, clinical findings and etiological factors in children born at term, affected by congenital hemiparesis

In order to examine if specific findings from CT correlate with specific clinical or neurological findings, 30 children, 5 to 16 years old, born at term, affected by congenital hemiparesis without intellectual impairment, were submitted to neurofunctional and psychological assessment and examined by CT. 28 of the 30 children had pathological CT. Two morphological CT patterns were found: A) Cavity in the cortex and underlying subcortical white matter (11 cases); B) Unilateral ventricular enlargement and paraventricular lesions (17 cases). CT was normal in two cases. In our children, born at term, no statistical correlation between CT patterns and anamnestic data was found as described in other studies, although in the patients with cortical-subcortical lesions, there was a slight prevalence of a history of perinatal complications, and in the patients with paraventricular lesions there was an uneventful history or abnormal pregnancy history. The relation between specific CT patterns (type A and B) and specific clinical dysfunction is not statistically evident, (unless for astereognosis and type A CT pattern). However, the patients with cortical-subcortical lesions showed a slight prevalence of a lower function of the impaired hand, and a higher percentage of an I.Q. of less than 90, than the group with unilateral ventricular enlargement. No relation was found between CT lesional pattern and epilepsy. The absence of correlation between morphological aspects and clinical findings could be explained by the complexity of structural changes and remodelling properties of the central nervous system, following prenatal and perinatal brain damage.

Development of language comprehension in preschool children: a picture identification test in the assessment of the comprehension of grammatical structures

A language comprehension test based on picture identification was administered to 180 normal children aged between 3 1/2 and 6 years. Of the 20 test items 11 correlated with age and with the development of linguistic abilities. The test is sufficiently discriminant in respect of comprehension of morphological-syntactic structures between the ages of 4 and 6 years.