Indocyanine green fluorescence imaging localization-assisted thoracoscopy revision surgery after repair of esophageal atresia

Revision surgery for the complications after repair of esophageal atresia is often complex because of previous surgeries and chest infections and thus requires surgical expertise. This study describes surgical experiences with the use of indocyanine green (ICG) fluorescence imaging localization-assisted thoracoscopy during revision surgery, including recurrent tracheoesophageal fistula (rTEF) (8 cases, one of which was esophageal-pulmonary fistula) and delayed esophageal closure (1 case).

We performed fistula repair and esophageal reconstruction according to the indications of ICG. The application of this method avoids the excessive trauma caused by freeing the trachea and esophagus. Contrast imaging taken one week and one month after surgery indicated no spillover of the contrast agent from the esophagus, except in 1 case. Indocyanine green fluorescence imaging localization-assisted thoracoscopy is worth promoting for revision surgery after esophageal atresia repair.

In summary, the use of indocyanine green fluorescence localization-assisted thoracoscopy for revision surgery to treat complications after esophageal atresia repair is a safe and reliable method that deserves promotion.

Twenty-Five-Year Experience with Minimally Invasive Splenectomy in Children: From Minilaparotomy to Use of Sealing Devices and Indocyanine Green Fluorescence Technology: Tips and Tricks and Technical Considerations

Background: This study aimed to review our 25-year experience with pediatric laparoscopic splenectomy (LS) and describe tips, tricks, and technical considerations.

Methods: The records of 121 children, undergoing minimally invasive splenectomy in the last 25 years (1996-2021), were retrospectively reviewed. Median patient age was 10.2 years (range 7-17). The patients were grouped according to the period: G1 (1996-2005) included 31 patients undergoing open splenectomy using left subcostal minilaparotomy (G1a) and 28 receiving LS using supine position (G1b); G2 (2006-2021) included 62 patients undergoing LS using lateral decubitus. A five-trocar technique was adopted in G1b, with the spleen removed through a Pfannenstiel incision. In G2, we preferred to use lateral decubitus, 10-mm 30° optic, only four trocars, and sealing devices. In such cases, the spleen was placed in an endobag, finger-fragmented, and extracted through the umbilicus. Furthermore, indocyanine green (ICG) fluorescence was used in the last 4 G2 patients to clearly identify the vascular anatomy.

Results: The median operative time was 65 minutes in G1a, 125 in G1b, and 95 in G2. Complications occurred intraoperatively in 14 cases (11.5%): 5 bleedings during dissection (G1b), 4 endobag breakages during spleen removal (G2); 3 spleen capsule breakages during removal (G1a); and 2 instrumentation failures (G2). No conversions to open occurred. Median hospital stay was 6 days in G1a and 4 days in G1b and G2.

Conclusions: LS is a standardized and effective procedure in children and is preferable to mini- or conventional open splenectomy. Our 25-year experience showed that major complications may occur even in expert hands, mainly during hilar dissection or spleen extraction. Technically, sealing devices and ICG fluorescence were helpful to perform a safer and faster procedure. We believe that lateral decubitus and 30° optic should be considered technical key points to provide excellent organ exposure and easier dissection of hilar structures.

Bowel perfusion demonstrated using indocyanine green fluorescence imaging in two cases of strangulated ileus

We report the use of indocyanine green (ICG) fluorescence for intraoperative diagnosis in two cases of strangulated ileus. We successfully preserved the bowel and avoided postoperative complications by detecting adequate perfusion and no necrosis in the intestine’s strangulated regions. In the first case, enhanced computed tomography (CT) revealed a closed loop intestine, which showed poor contrast, and we performed laparotomy with ICG fluorescence. In the second case, the CT scan revealed bowel obstruction without ascites. We conservatively treated the patient with the insertion of a long tube. The patient’s condition did not improve, and we performed laparotomy using ICG fluorescence. In both of these cases, the visual observation during laparotomy showed that the ileum had dark-red discoloration. We demonstrated perfusion and preserved the ileum by injecting 2.5 mg of ICG intravenously; fluorescence was observed in the dark-red ileum using the PINPOINT system (Novadaq, Kalamazoo, MI, US). Both patients recovered successfully after the surgery with no adverse events. Our data suggest that ICG fluorescence imaging can be one of the decision-making modalities in patients with strangulated ileus.

EAES this week in Poland

So many talks on ICG this week at event including results from EssentiAL study from Japan, talks on ICG and Fluorescence by  Madhi Al-Taher, Ludovica Baldari, Niall Hardy, Manish Chand, Diego Coletta, Leonardo Rossa, Hanneke Joosten, Clarisa Birlog, Francesco Mongelli, Francesco Calabrese, Vera D’Abrosca, Daan Sikkenk, Antonio Soares, Ichiro Takemasa, Zaid Al Difaie, Gianlorenzo Dionigi, Hans Fuchs, Silvia Quaresima, Francesco Pietro Maria Roscio, Andrea Balla– check out the programme link

Hope to see you there!

Clinical Benefits of Indocyanine Green Fluorescence in Robot-Assisted Partial Nephrectomy

Background: To compare the intraoperative and postoperative outcomes of indocyanine green (ICG) administration in robot-assisted partial nephrectomy (RAPN) and report the differences in the results between patients with benign and malignant renal tumors.

Methods: From 2017 to 2020, 132 patients underwent RAPN at our institution, including 21 patients with ICG administration. Clinical data obtained from our institution’s RAPN database were retrospectively reviewed. Intraoperative, postoperative, pathological, and functional outcomes of RAPN were assessed.

Results: The pathological results indicated that among the 127 patients, 38 and 89 had received diagnoses of benign and malignant tumors, respectively. A longer operative time (311 vs. 271 min; p = 0.006) but superior preservation of estimated glomerular filtration rate (eGFR) at 3-month follow-up (90% vs. 85%; p = 0.031) were observed in the ICG-RAPN group. Less estimated blood loss, shorter warm ischemia time, and superior preservation of eGFR at postoperative day 1 and 6-month follow-up were also noted, despite no significant differences. Among the patients with malignant tumors, less estimated blood loss (30 vs. 100 mL; p < 0.001) was reported in the ICG-RAPN subgroup.

Conclusions: Patients with ICG-RAPN exhibited superior short-term renal function outcomes compared with the standard RAPN group. Of the patients with malignant tumors, ICG-RAPN was associated with less blood loss than standard RAPN without a more positive margin rate. Further studies with larger cohorts and prospective designs are necessary to verify the intraoperative and functional advantages of the green dye.

Indocyanine green fluorescence: A surgeon’s tool for the surgical approach of gallstone ileus

The application of indocyanine green fluorescent could be a useful tool during the surgical management of biliary fistulas and gallstones, focused on improving the visualization of structures and decreasing the risk of injury. Gallstone ileus is a mechanical obstruction secondary with one or more biliary stones in the small bowel or any part of the gastrointestinal tract; the stone passes through a biliary tract´s fistula.  This stone obstructs the distal ileum and the ileocecal valve in 50%–75% of the occasions, and just 4% obstructs the outlet gastric tract.  We present a case of a gallstone ileus patient, where we describe the application of the indocyanine green fluorescence that could help reduce common bile duct injuries and improve the therapeutic of these patients.

Quantification of gastric tube perfusion following esophagectomy using fluorescence imaging with indocyanine green

Anastomotic leakage (AL) remains a prevalent and life-threatening complication after esophagectomy. Gastric tube perfusion assessment using indocyanine green fluorescence imaging (ICG-FI) has been published in several studies and appears to be a promising tool to reduce AL rates by changing the surgical approach, namely by an intraoperative evaluation of the anastomosis localization.

In this study, gastric tube perfusion was quantified by using ICG-FI in 20 high-risk patients undergoing esophagectomy. From a time-dependent fluorescence intensity curve, the following three parameters were evaluated: slope of fluorescence intensity (SFI), background subtracted peak fluorescence intensity (BSFI), and time to slope (TTS). The values between pyloric region and tip showed a similar downward trend and SFI and BSFI significantly correlated with the distance to the pyloric region. SFI and BSFI were significantly decreased at the tip of the gastric tube. The placement of anastomosis in an area with homogenous fluorescence pattern was correlated with no AL in 92.9% of cases. An inhomogeneous fluorescence pattern at anastomotic site was a risk factor for the occurrence of an AL (p < 0.05). Reduction of perfusion up to 32% using SFI and up to 23% using BSFI was not associated with AL.

Conclusion: ICG-FI can be used to quantify the gastric tube perfusion by calculating SFI, BSFI, and TTS. The anastomosis should be created in areas with homogeneous fluorescence pattern. A reduction in blood flow of up to 32% can be accepted without causing an increased rate of insufficiency.

Role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery: a systematic review

Our aim was to review the current knowledge of the role of fluorescence imaging for intraoperative intestinal assessment in gynecological surgery.

Material and methods: A computer-based systematic review was performed from 2000 to 2020. All articles describing the use of indocyanine green (ICG) applied to bowel assessments in gynecology or endometriosis surgery were considered for review.

Results: ICG is an effective tool for assessing bowel vascularization, potentially preventing anastomotic leakage and recto-vaginal fistula and can therefore be useful for endometriosis surgery or bowel assessment in gynecological oncology procedures. Real-time characterization of the hypovascular pattern of endometriotic nodules has been associated with a larger nodule size and lower microvessel density, helping surgeons choose the best transecting line and the most appropriate technique. ICG angiography allows for a laparoscopic and intrarectal bowel assessment, which can act as a double check of bowel perfusion, enabling the assessment of mucosa vascularization. ICG fluorescence can guide intraoperative decision-making after intestinal anastomosis, discoid resection, and rectal shaving, preventing anastomotic leakage and postoperative recto-vaginal fistula in low anterior resections.

Conclusions: ICG angiography provides a better intestinal assessment. Larger, prospective, randomized controlled studies are needed to validate the technique and confirm these encouraging results.

Utility of indocyanine green videoangiography with FLOW 800 analysis in brain tumour resection as a venous protection technique

In regard to central nervous system tumour resection, preserving vital venous structures to avoid devastating consequences such as brain oedema and haemorrhage is important. However, in clinical practice, it is difficult to obtain clear and vivid intraoperative venous visualization and blood flow analyses. We retrospectively reviewed patients who underwent brain tumour resection with the application of indocyanine green videoangiography (ICG-VA) integrated with FLOW 800 from February 2019 to December 2020 and present our clinical cases to demonstrate the process of venous preservation. Galen, sylvian and superior cerebral veins were included in these cases. Clear documentation of the veins from different venous groups was obtained via ICG-VA integrated with FLOW 800, which semiquantitatively analysed the flow dynamics. ICG-VA integrated with FLOW 800 enabled us to achieve brain tumour resection without venous injury or obstruction of venous flux. ICG-VA integrated with FLOW 800 is an available method for venous preservation, although further comparisons between ICG-VA integrated with FLOW 800 and other techniques of intraoperative blood flow monitoring is needed.