Effectiveness and safety of tumor site marking with near-infrared fluorescent clips in colorectal laparoscopic surgery: A case series study

Diagnostic Performance of Near-Infrared Fluorescent Marking Clips in Laparoscopic Gastrectomy

INTRODUCTION

Accurate tumor localization and resection margin acquisition are essential in gastric cancer surgery. Preoperative placement of marking clips in laparoscopic gastrectomy as well as intraoperative gastroscopy can be used for gastric cancer surgery. However, these procedures are not available at all institutions. We conducted a prospective clinical trial to investigate the diagnostic performance of near-infrared fluorescent clips (ZEOCLIP FS) in laparoscopic gastrectomy.

MATERIALS AND METHODS

Patients with gastric cancer or neuroendocrine tumor in whom laparoscopic distal, pylorus-preserving, or proximal gastrectomy was planned were enrolled (n = 20) in this study. Fluorescent clips were placed proximal and/or distal to the tumor via gastroscopy on the day before surgery. During surgery, the clips were detected using a fluorescent laparoscope, and suturing was performed where fluorescence was detected. The clip locations were then confirmed via gastroscopy, and the stomach was transected. The primary endpoint was the detection rate of the marking clips using fluorescence, and the secondary endpoints were complications and distance between the clips and stitches.

RESULTS

Among the 20 patients enrolled, distal and pylorus-preserving gastrectomies were performed in 18 and 2 patients, respectively. All clips were detected in 15 patients, indicating a detection rate of 75.0% (90% confidence interval: 54.4%-89.6%). Furthermore, no complications related to the clips were observed. The median distance between the clips and stitches was 5 (range, 0-10) mm.

CONCLUSIONS

We report the feasibility and safety of preoperative placement and intraoperative detection of near-infrared fluorescent marking clips in laparoscopic gastrectomy.

Fluorescence guidance using near-infrared fluorescent clips in robotic rectal surgery: a case series

PURPOSE

Tattoo markings are often used as preoperative markers for colorectal cancer. However, scattered ink markings adversely affect tumor site recognition intraoperatively; therefore, interventions for rectal cancer may lead to an inaccurate distal resection margin (DRM) and incomplete total mesorectal excision (TME). This is the first case series of fluorescence-guided robotic rectal surgery in which near-infrared fluorescence clips (NIRFCs) were used to localize rectal cancer lesions.

METHODS

We enrolled 20 consecutive patients who underwent robotic surgery for rectal cancer between December 2022 and December 2023 in the current study. The primary endpoints were the rate of intraoperative clip detection and its usefulness for marking the tumor site. Secondary endpoints were oncological assessments, including DRM and the number of lymph nodes.

RESULTS

Clip locations were confirmed in 17 of 20 (85%) patients. NIRFCs were not detected in 3 out of 7 patients who underwent preoperative chemoradiation therapy. No adverse events, including bleeding or perforation, were observed at the time of clipping, and no clips were lost. The median DRM was 55 mm (range, 22-86 mm) for rectosigmoid (Rs), 33 mm (range, 16-60 mm) for upper rectum (Ra), and 20 mm (range, 17-30 mm) for low rectum (Rb). The median number of lymph nodes was 13 (range, 10-21).

CONCLUSION

The rate of intraoperative clip detection, oncological assessment, including DRM, and the number of lymph nodes indicate that the utility of fluorescence-guided methods with NIRFCs is feasible for rectal cancer.

Use of inducible and limiting fluorescence in laparoscopic endoscopic cooperative surgery

Video 1Demonstration of the special use of the near-infrared fluorescent clip in laparoscopic endoscopic cooperative surgery.

Efficacy and Safety of Gastrointestinal Tumour Site Marking with da Vinci-Compatible Near-Infrared Fluorescent Clips: A Case Series

BACKGROUND

The conventional near-infrared fluorescent clip (NIRFC) ZEOCLIP FS® has been used successfully in marking tumour sites during laparoscopic surgeries. However, this clip is difficult to observe with the Firefly imaging system equipped with the da Vinci® surgical system. We have been involved in the modification of ZEOCLIP FS® and development of da Vinci-compatible NIRFC. This is the first prospective single-centre case series study verifying the usefulness and safety of the da Vinci-compatible NIRFC.

METHODS

Twenty-eight consecutive patients undergoing da Vinci®-assisted surgery for gastrointestinal cancer (16 gastric, 4 oesophageal, and 8 rectal cases) between May 2021 and May 2022 were enrolled.

RESULTS

Tumour location was identified by the da Vinci-compatible NIRFCs in 21 of 28 (75%) patients, which involved 12 gastric (75%), 4 oesophageal (100%), and 5 rectal (62%) cancer cases. No adverse events were observed.

CONCLUSION

Tumour site marking with da Vinci-compatible NIRFC was feasible in 28 patients enrolled in this study. Further studies are warranted to substantiate the safety and improve the recognition rate.

Preoperative tumor marking with indocyanine green (ICG) prior to minimally invasive colorectal cancer: a systematic review of current literature

AIM

To describe the currently available evidence regarding the efficacy and safety of preoperative tumor marking using indocyanine green (ICG) prior to laparoscopic or robotic colorectal resections.

METHODS

A systematic search for relevant studies was conducted using the following databases: Embase (OVID), MEDLINE® (OVID), APA PsycInfo (OVID), Global Health (OVID) and HMIC Health Management Information Consortium (OVID) through June 2022 reported according to PRISMA 2020 guidelines. Primary outcome was the detection rate of the tumor sites preoperatively marked with ICG. Secondary outcomes were timing of ICG injection in days prior to the operation and technique-related complications.

RESULTS

Eight single center studies, published between 2008 and 2022, were identified yielding a total of 1,061 patients, of whom 696 were preoperatively tattooed with ICG. Injection dosage of diluted ICG ranged from 0.1-1.5 ml. Four studies used the saline test injection method prior to ICG injection. When the marking was placed within one week, the visualization rate was 650/668 (97%), whereas when it was longer than one week, the detection rate was 8/56 (14%). No severe complications were reported.

CONCLUSION

Preoperative tumor marking using ICG prior to minimally invasive colorectal resections is safe and effective, allowing intraoperative tumor site location when performed up to a week prior to surgery without disturbing the surgical view in potential mild complications.

Effectiveness of fluorescence-guided methods using near-infrared fluorescent clips of robotic colorectal surgery: a case report

BACKGROUND

This is the first report on the application of the Da Vinci-compatible near-infrared fluorescent clips (NIRFCs) as tumor markers to localize colorectal cancer lesions during robotic surgery. In laparoscopic and robotic colorectal surgeries, the accuracy of tumor marking is a critical issue that remains unresolved. This study aimed to determine the accuracy of NIRFCs in localizing tumors for intestinal resection. Indocyanine green (ICG) was also used to verify the feasibility of safely performing an anastomosis.

CASE PRESENTATION

A patient diagnosed with rectal cancer was scheduled to undergo a robot-assisted high anterior resection. During colonoscopy 1 day prior to the surgery, four Da Vinci-compatible NIRFCs were placed intraluminally 90° around the lesion. The locations of the Da Vinci-compatible NIRFCs were confirmed using firefly technology, and ICG staining was performed before cutting the oral side of the tumor. The locations of the Da Vinci-compatible NIRFCs and the intestinal resection line were confirmed. Moreover, sufficient margins were obtained.

CONCLUSIONS

In robotic colorectal surgery, fluorescence guidance with firefly technology offers two advantages. First, it has an oncological advantage, because marking with the Da Vinci-compatible NIRFCs allows for real-time monitoring of the lesion location. This enables sufficient intestinal resection by grasping the lesion precisely. Second, it reduces the risk of postoperative complications, because ICG evaluation with firefly technology prevents postoperative anastomotic leakage. Fluorescence guidance in robot-assisted surgery is useful. In the future, the application of this technique should be evaluated for lower rectal cancer.

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

BACKGROUND

Indocyanine green (ICG) imaging has been increasingly used for intraoperative guidance in colorectal surgery over the past decade. The aim of this study was to review and organize, according to different type of use, all available literature on ICG guided colorectal surgery and highlight areas in need of further research and discuss future perspectives.

METHODS

PubMed, Scopus, and Google Scholar databases were searched systematically through November 2022 for all available studies on fluorescence-guided surgery in colorectal surgery.

RESULTS

Available studies described ICG use in colorectal surgery for perfusion assessment, ureteral and urethral assessment, lymphatic mapping, and hepatic and peritoneal metastases assessment. Although the level of evidence is low, results are promising, especially in the role of ICG in reducing anastomotic leaks.

CONCLUSIONS

ICG imaging is a safe and relatively cheap imaging modality in colorectal surgery, especially for perfusion assessment. Work is underway regarding its use in lymphatic mapping, ureter identification, and the assessment of intraperitoneal metastatic disease.

Preoperative tumor marking with indocyanine green prior of robotic colorectal resections

This prospective case-series study aimed to assess the usefulness of preoperative colonoscopic marking of colorectal tumors using Indocyanine Green (ICG) fluorescence in patients that underwent robotic surgical colorectal resections. Consecutive patients that were eligible for colorectal resection with intent to cure in a single hospital (Athens Medical Center), from February 2022 to June 2022, were included. ICG solution was injected into the submucosal layer at 2 opposite sites (180 degrees apart) distal to the tumor, without submucosal elevation. Identification of the tumor marking was then performed after switching to near-infrared (NIR) fluorescence mode. During the robotic procedure, qualitative evaluation of fluorescence was performed by the surgical team (primary surgeon, first assistant, second assistant, research fellow). All 10 patients underwent robotic surgical approach and operations included right-sided colectomy (n = 1), left-sided colectomy (n = 6) and low anterior resection (n = 3). Visualisation of this dye with near-infrared light was very clear with bright intensity in all patients when the marking was performed one day prior of surgery. Preoperative tumor marking with ICG was identified intraoperatively in all cases and the techinque was easily reproducible.

Intraoperative Tumor Identification During Laparoscopic Distal Gastrectomy: a Novel Fluorescent Clip Marking Versus Metal Clip Marking and Intraoperative Gastroscope

BACKGROUND

In complete laparoscopic distal gastrectomy, the gastric resection line is difficult to determine due to a lack of tactile sensation. The use of intraoperative gastroscopy and intraoperative radiography has been reported, but the burden on personnel and technical complexity present impediments. In our department, based on lesion extent determined with preoperative gastroscopy, a fluorescent clip is used to mark the oral side of the lesion, which is resected after confirmation with a fluorescent laparoscopic system. In this study, we investigated the efficacy of fluorescent clip marking (FCM) in achieving an accurate resection line and reducing the operative time.

METHODS

Fifty-six patients with gastric cancer who underwent complete laparoscopic distal gastrectomy from January 2018 to March 2021 were divided into two groups: the FCM group (n = 32) and the conventional metal clip marking and intraoperative gastroscopy (MCMG) group (n = 24). Short-term outcomes, including the resection margins, gastric resection time, and operative time, were compared and examined.

RESULTS

The fluorescent clips were visible in all cases, and all stumps were negative according to permanent preparations. The operative times for FCM and MCMG were 350 (216-533) vs. 373.5 (258-651) min, respectively, with no significant difference (p = 0.316), while the gastric resection times were 636.5 (321-2572) vs. 1457.5 (843-4973) s, respectively, and were significantly shorter in the FCM group (p < 0.0001).

CONCLUSIONS

FCM shortened the gastric resection time and could possibly shorten the operative time. FCM is feasible and safe and can potentially be used as a tumor-marking agent to determine accurate surgical resection lines.

CLINICAL TRIAL REGISTRATION

Examination of Gastric Cancer, Research Ethics Committee of the Kawaguchi Municipal Medical Centre (Saitama, Japan), approval number: 2019-33. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.

A case in which a near-infrared ray catheter (NIRC) was effectively applied in laparoscopic sigmoidectomy for a sigmoidovesical fistula

A 40-year-old man visited the hospital for a refractory urinary tract infection. A sigmoidovesical fistula resulting from a sigmoidovesical diverticulum was diagnosed, and laparoscopic surgery was performed. To avoid ureteral injury during surgery for highly advanced cancer and inflammatory diseases, a ureteral stent is generally placed before the procedure. However, in this case, surgery was performed using a near-infrared ray catheter (NIRC), which emits fluorescence when irradiated with near-infrared light. By clearly observing the pathway of the ureter via near-infrared light, the integrity of the ureter could be preserved, and sigmoidectomy was safely performed. The visual navigation of the ureter with NIRC was especially useful during surgery for a colovesical fistula with marked surrounding inflammatory changes and a high risk of ureteral damage.

Tattooing or Metallic Clip Placement? A Review of the Outcome Surrounding Preoperative Localization Methods in Minimally Invasive Anterior Resection Performed at a Single Center

BACKGROUND

For minimally invasive colorectal surgery, preoperative localization is a typical procedure. We here aimed to analyze compared 2 different localization methods in terms of short-term outcomes, like the operative outcome and postoperative complication rates based on real-world data.

MATERIALS AND METHODS

This was a retrospective analysis study conducted at a medical center. We enrolled patients who were presented with colonic tumor between January 1, 2016, and December 31, 2019, and they had undergone laparoscopic anterior resection in a single institution. Data included patient characteristics, operative outcome, length of hospital stay, and postoperative complications.

RESULTS

The preoperative localization group had a better resection margin (4 vs. 3 cm; P<0.001) and fewer procedures of intraoperative colonoscopy (4.67% vs. 18.22%; P=0.002). Lymph node harvest occurred more in patients with endoscopic tattooing procedures than with metallic clip procedures (25 vs. 20; P=0.031). No significant difference was found regarding postoperative complications and the length of hospital stay.

CONCLUSIONS

Preoperative localization in a laparoscopic anterior resection led to better surgical planning and resection margin. The metallic clip placement was helpful in the preoperative localization and setting. The endoscopic tattooing method had a larger lymph node harvest and with fewer intraoperative colonoscopy.

Clinical role of fluorescence imaging in colorectal surgery - an updated review

INTRODUCTION

Colorectal surgery has markedly advanced due to the introduction of laparoscopic and robotic surgery. During the past 20 years, these two modalities have been further enhanced by fluorescence imaging.

AREAS COVERED

This article will review the common and novel uses for fluorophores in colorectal surgery, including tissue perfusion for anastomotic creation, ureter identification, lymphatic mapping, and tumor localization.

EXPERT OPINION

The versatility of this technology permeates through many aspects of colorectal procedures. The white light spectrum has historically been the only available modality to visualize tissue perfusion, tumor implants, and structures including the ureters and lymph nodes. The ability of the near-infrared spectrum to penetrate biologic tissues allows the identification of these structures with injection of fluorophores. The two most common intravenously utilized fluorophores are methylene blue and indocyanine green. Additionally, novel tumor marker-specific fluorophores are being investigated for purposes of cancer detection.

Preoperative Colonoscopic Tattooing Using a Direct Injection Method with Indocyanine Green for Localization of Colorectal Tumors: An Efficacy and Safety Comparison Study

Purpose

Methods

Results

Conclusion