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.

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.

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