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.


Effect of Indocyanine Green Fluorescence Angiography on Anastomotic Leakage in Patients Undergoing Colorectal Surgery: A Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies

Background: Meta-analyses have demonstrated that indocyanine green (ICG) can effectively prevent anastomotic leakage (AL) after colorectal surgery. However, recent evidence from large randomized controlled trial (RCT) has suggested that ICG fluorescence angiography does not reduce the incidence of AL in colorectal surgery. This study was conducted to evaluate the value of ICG for the prevention of AL following colorectal surgery.

Results: Twenty studies (5 RCTs and 15 PSM studies) with a total of 5,125 patients were included. ICG did not reduce the reoperation rate (OR, 0.71; 95% CI, 0.38, 1.30), conversion rates (OR, 1.34; 95% CI, 0.65, 2.78), or mortality (OR, 0.50; 95% CI, 0.13, 1.85), but ICG did reduce the incidence of AL (OR, 0.46; 95% CI, 0.36, 0.59) and symptomatic AL (SAL) (OR, 0.48; 95% CI, 0.33, 0.71), and reduced the length of hospital stay (MD,−1.21; 95% CI,−2.06,−0.35) and intraoperative blood loss (MD,−9.13; 95% CI,−17.52,−0.74). In addition, ICG use did not increase the incidence of total postoperative complications (OR, 0.93; 95% CI, 0.64, 1.35), postoperative ileus (OR, 1.26; 95% CI, 0.53, 2.97), wound infection (OR, 0.76; 95% CI, 0.44, 1.32), urinary tract infection (OR, 0.87; 95% CI, 0.30, 2.59), pulmonary infection (OR, 0.23; 95% CI, 0.04, 1.45), urinary retention (OR, 1.08; 95% CI, 0.23, 5.04), anastomotic bleeding (OR, 1.53; 95% CI, 0.27, 8.60), anastomotic stricture (OR, 0.74; 95% CI, 0.24, 2.29), or operative time (MD,−9.64; 95% CI,−20.28, 1.01).

The meta-analysis showed that ICG can effectively reduce the AL rate, SAL rate, blood loss, and hospital stays, without prolonging the operation time or increasing postoperative complications in colorectal surgery. …We found that ICG use was associated with a reduced incidence of SAL. Previous studies have shown that the incidence of AL is related to the position of the anastomotic, and the lower the position, the higher the risk of AL (23, 47). Therefore, the trial of low anterior resection was used as a subgroup in this study, and the results of subgroup analysis showed that ICG could effectively reduce the incidence of AL in this high-risk population. Similarly, a retrospective study by Jafari et al. (15) found that the risk of AL in robot-assisted rectal surgery was reduced to 6% in the ICG group, compared with 18% in the control group.

Conclusions: ICG can effectively reduce the incidence of AL, without prolonging the operation time or increasing postoperative complications in colorectal surgery.


Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers

Background: The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications.Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021.

One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks.

Conclusion: ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.


Vistamerica announced the approval of VistaVerde ICG in Mexico

ICG available in Mexico

ICG now approved in Mexico – Vistamerica announced the approval of VistaVerde ICG in Mexico: Available on market in October 2020

Puerto Peñasco, Sonora.  August 20, 2020.  Vistamerica S de RL is proud to announce that VistaVerde ICG has been approved by the Federal Committee for Protection from Sanitary Risks (COFEPRIS) in Mexico. Vistamerica has exclusive distribution rights for Indocyanine Green (ICG) for the entire territory of Mexico, with plans set to enter the market in October 2020.

ICG, produced by Michigan based Diagnostic Green LLC, the leading provider of trusted high-quality fluorescence pharmaceutical products, is well known and accepted by physicians worldwide. Indicated for use in determining cardiac output, hepatic function and liver blood flow, and for ophthalmic angiography, ICG is well tolerated and has an excellent safety profile.  It is routinely used by physicians during fluorescent guided surgery. 

“We are delighted to engage with such a dedicated and enthusiastic company that will ensure ICG will be available to physicians throughout Mexico”, stated Ron Clarke, VP Business Development at Diagnostic Green. 

Vistamerica cofounder and owner Catalina Markham similarly expressed, “We are excited to offer ICG in Mexico. It is quickly becoming the standard of care during fluorescent guided surgery and we are anxious to continue providing excellent service with cutting-edge products to benefit physicians and patients alike.”

For full prescribing details, contact Vistamerica. 

Vistamerica S de RL Sinaloa Avenue No. 183-3, South Center, 83550, Puerto Peñasco, Sonora, Mexico.

Office: + 52-638-38-88668, Info@vistamerica.net.


Verde de Indocianina

ICG ahora aprobado en México – Vistamerica anunció la aprobación de VistaVerde ICG en México: Disponible en el mercado en octubre del 2020

Puerto Peñasco, Sonora, 20 de agosto, 2020. Vistamerica S de RL (Vistamerica) se enorgullece de anunciar que VistaVerde ICG ha sido aprobado por la Comision Federal de Protección contra Riesgos Sanitarios (COFEPRIS) en México. Vistamerica tiene los derechos exclusivos de distribución de Indocyanine Green (ICG) para todo el territorio de México, con planes para ingresar al mercado en octubre del 2020.

ICG, es producido por Diagnostic Green LLC, con sede en Michigan, proveedor líder de productos farmacéuticos de fluorescencia de alta calidad de confianza, es bien conocido y aceptado por médicos de todo el mundo. Indicado para su uso en la determinación del gasto cardíaco, la función hepática y el flujo sanguíneo hepático, y para la angiografía oftálmica, el ICG se tolera bien y tiene un excelente perfil de seguridad. Los médicos lo utilizan habitualmente durante la cirugía guiada por fluorescencia.

“Estamos encantados de colaborar con una empresa tan dedicada y entusiasta que garantizará que ICG esté disponible para los médicos en todo México”, afirmó Ron Clarke, vicepresidente de desarrollo comercial de Diagnostic Green.

La cofundadora y propietaria de Vistamerica, Catalina Markham, expresó de manera similar: “Estamos muy contentos de ofrecer ICG en México. ICG se está convirtiendo rápidamente en el estándar de atención durante la cirugía guiada por fluorescencia y estamos ansiosos por continuar brindando un servicio excelente con productos de vanguardia para beneficiar a médicos y pacientes por igual”.

Para obtener detalles completos, comuníquese a Vistamerica.

Vistamerica S de RL Avenida Sinaloa No. 183-3, Centro Sur, 83550, Puerto Peñasco, Sonora, México.

Oficina: + 52-638-38-88668, Info@vistamerica.net.

The SAGES 2020 Annual Meeting is Virtual, 11-13 August

From August 11-13, the annual SAGES event will take place virtually. Consisting of three days of live programming, educational events, workshops and networking sessions where you can virtually mingle with other SAGES members and leadership.

Not only does the SAGES Virtual event promise a jam packed itinerary, it also has a virtual exhibition area for industry and Diagnostic Green are delighted to take part. By logging onto the SAGES exhibition area here you can access useful information from Diagnostic Green on the use of Indocyanine Green in Fluorescence Guided Surgery.

We showcase a case study, from Dr. Steven Wexner, MD, Cleveland Clinic Florida on “Evaluation of Anastomotic Perfusion following Laparoscopic Anterior Resection with Coloanal Anastomosis” and extracts from the white paper “Economic Health Technology Assessment (HTA) Approach on Surgical Endoscopy Procedures using Indocyanine Green (ICG)”. All this can be found here.

Register here to enjoy three days of unmissable information from The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 

Live Webinar: ISFGS Round Table 13th August 2020

Defining Standards in Fluorescence Guided Surgery

The International Society for Fluorescence Guided Surgery will host a round table on August 13th 2020, 9.00pm EST Time (US and Canada).

The round table will be facilitated through a live webinar and will feature a discussion from Dr. Raul Rosenthal, Dr. Fernando Dip, Dr. Michael Bouvet and Dr. Eren Berber on the standards of fluorescence guided surgery and the use of Indocyanine Green, ICG in endocrine surgery.

If you wish to register, go to the link here, spaces are limited.

Use of NIFC Cholangiography for the Identification of the Anatomy in Biliary Surgery

Use of Near-infrared Incisionless Fluorescent Cholangiography (NIFC) for Identification of the Anatomy in Biliary Surgery Francisco

Authors: A. Ferri, MD; Felice De Stefano, MD; Vicente J. Cogollo, MD; Alejandro Cracco, MD; Emanuele Lo Menzo, MD, PhD, FACS, FASMBS; Mayank Roy, MD, FACS; Fernando Dip, MD, FACS.
Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida.

Summary: Bile duct injuries during laparoscopic cholecystectomy remain a potentially devastating complications and are responsible for major morbidity and prolonged hospitalization1. Visual misperception, anatomical variations in the extrahepatic biliary tree, combined with inflammatory changes and surgeon inexperience in recognizing the anatomy, are among the most common reasons for these injuries. Near-infrared Incisionless Fluorescent Cholangiography (NIFC) has been shown to improve the visualization and identification of the biliary structures compared to traditional white light.

Patient Background: The following case study discusses a 37 years old, morbidly obese woman (BMI 43 Kg/m2) with impaired fasting glucose and no significant surgical history who presented to the clinic with a 3-month history of right upper quadrant (RUQ) abdominal pain, especially after meals. The physical exam revealed tenderness in the RUQ with a negative Murphy sign and no evidence of peritonitis. An ultrasound showed a 3.8 cm gallstone without gallbladder wall thickening and hepatic steatosis. Esophagogastroduodenoscopy did not reveal any pathologic findings. The patient was referred to the bariatric surgery clinic for evaluation in view of her elevated BMI and her comorbidity. After discussing surgical options, the patient elected to undergo a combined laparoscopic sleeve gastrectomy and cholecystectomy using NIFC.

Procedure: Under general anesthesia, the abdominal cavity was accessed through an optical trocar in the supraumbilical position. After insertion of accessory trocars, a sleeve gastrectomy was performed in standard fashion. Next, 3mL of Indocyanine green for Injection, USP (ICG) were injected
intravenously. The gallbladder was cranially retracted. The hepatoduodenal ligament was exposed. Using near-infrared imaging we identified the ICG perfusion times of the liver, common hepatic duct and gallbladder at 1, 12 and 22 minutes after the injection of the ICG, respectively (Figures 2-4).
The cystic duct and cystic artery entrance into the gallbladder were both clearly identified (Figure 5) and transected between clips. The very large and chronically inflamed gallbladder was excised from the liver bed in retrograde fashion and retrieved with the specimen through the umbilicus. All trocar sites were closed with sutures and injected with local anesthesia.

For images, references and conclusions please click here

HTA Approach on Surgical Endoscopy Procedures using ICG

Indocyanine Green ICG use in Fluorescence Guided Surgery

Economic Health Technology Assessment (HTA) Approach on Surgical Endoscopy Procedures using Indocyanine Green (ICG)

Authors: Vettoretto, N; Foglia, E; Ferrario, L; Gerardi, C; Molteni, B; Nocco, U; Lettieri, E; Molfino, S; Baiocchi, G.L; Elmore, U; Rosati, R; Currò, G; Cassinotti, E; Boni, L; Cirocchi, R; Marano, A, Petz, W.L; Arezzo, A; Bonino, M.A; Davini, F; Biondi, A; Anania A; Agresta, A; Silecchia, G.

This paper offers a summary of a number of key findings published in Surgical Endoscopy, April 2020.
Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

A paper published in Surgical Endoscopy, April 2020, undertook a Health Technology Assessment (HTA) approach to investigate the economic, social, ethical and organizational implications related to the adoption of ICG based fluorescence guided surgery, summurizing the key findings.

With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated Questionnaires and self reported interviews. Research included a systematic search of literature. This present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an Health Technology Assessment (HTA) approach, supports “the use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology”.

The use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology

Recently image-guided by indocyanine green (ICG) fluorescence has been introduced in minimally invasive clinical practice. The fluorescence approach is detected thanks to special cameras that are sensitive to the nearinfrared (NIR) spectrum. Indocyanine Green (ICG) absorbs Near-infrared light (NIR) at wavelengths of 800 to 810 nm. This fluorophore emits fluorescence at 830 nm when bound to tissue proteins if excited, with specific wavelength light in the Near-infrared light (NIR) spectrum (w820 nm).

85% of those interviewed believe Indocyanine Green (ICG) Fluorescence Guided Surgery will become standard in the near future

Fifty-six surgeons working in both teaching and community, public and private hospitals (covering 75% of the Italian regions), answered a questionnaire. 66.1% of the respondents already used fluorescence during their everyday practice. 63.3% of the surgeons consider Indocyanine Green (ICG) fluorescence guided surgery as an improvement of their practice, while 62.5% think that this technology can help in surgical education. When asked about the potential growth of Indocyanine Green (ICG), 85% of those interviewed believe that it has the potential to become a standard vision technology, in the near future.

“The use of ICG is perceived as improving the precision of the surgical technique, the identification of the blood vessels, allowing for a better image quality compared with standard white light”

To read the full summary of the paper click here

Full reference Source: Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment (HTA) summary