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Real-Time assessment of intestinal perfusion and lymphatic flow by Indocyanine Green Fluorescence Image–Guided Laparoscopic Surgery for colo-rectal cancers

Goutaro Katsuno, MD, PhD1, Yasuhiko Nakata, MD, PhD1, Nobuyuki Kubota, MD, PhD1, Teruo Kaiga, MD, PhD1, Takao Mamiya, MD1, Masahiro Yan, MD1, Naoaki Shimamoto, MD1, Shuichi Sakamoto, MD, PhD2. 1Department of Gastrointestinal and Minimally Invasive Surgery, Mitsuwadai General Hospital, 2Sakamoto Clinic

Introduction: Recently major developments in video imaging have been achieved for performing complete mesocolic excisions (CME) or total mesorectum excisions (TME). Indocyanine green (ICG) fluorescence imaging is already contributing greatly to making intraoperative decisions for keeping an intact visceral fascial layer, making suitable mesentery division lines and identifying anastomotic perfusions. The aim of this study is to present our experience with laparoscopic procedures for colo-rectal cancers using ICG fluorescence imaging (LAP ICG-FI).

Patients and Methods: We usually use the near-infrared (NIR) laparoscopy (Stryker Corporation, Michigan, USA) for LAP ICG-FI.

 [Indocyanine green fluorescent imaging]

Visualization of lymph flow: ICG (2.5 mg/1.0 mL) was injected into the submucosal layer around the tumor at 2 points with a 23-gauge localized injection before the lymph node dissection .

Visualization of blood flow: After complete colorectal mobilization, the mesocolon was completely divided at the planned proximal or distal transection line. Indocyanine green was injected intravenously and the transection location(s) and/or distal rectal stump, if applicable, were re-assessed in fluorescent imaging mode.

Results: We experienced 32 LAP ICG-FI cases with colo-rectal cancer patients. Tumor was located at the rectum in 12 of them, at the sigmoid colon in 10, at the transverse colon in 2, at the descending colon in 2, at the ascending colon in 4, and at the cecum in 2. TNM stage was 0-I in 10 patients, II in 9, III in 8, and IV in 5. The median (range) age of the patients was 68(55–77) years with a median (range) BMI of 24.8 (20–36.4) kg/m2.  The lymph flow was visualized in 30 patients (94%) intraoperatively. However, a high-quality intraoperative ICG lymphangiogram was achieved in 22 patients (73%). In high-quality lymphangiogram, the lymphatic ducts and lymph nodes were clearly visualized in real time, and this proved useful in keeping an intact visceral fascial layer as well as in making a suitable mesentery division line even in the BMI>30 patients. A high-quality intraoperative ICG angiogram was achieved in all patients. Anastomotic perfusion was satisfactory in all cases. In 2 patients (6.3%), the use of NIR+ICG resulted in revision of the proximal colonic transection point before formation of the anastomosis. There were no postoperative anastomotic leakages. No injection-related adverse effects were reported.

Conclusion: LAP ICG-FI is a simple, safe and useful tool to help us complete LAP CME or TME and check real-time anastomotic tissue perfusion.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 86185

Program Number: P483

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

13

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