Indocyanine Green Angiography Precise Marking for Indeterminate Burn Excision: A Prospective, Multi-centered, Double-blinded Study

Utility of indocyanine green fluorescent dye in emergency general surgery: a review of the contemporary literature

For decades, indocyanine green (ICG) has been available for medical and surgical use. The indications for ICG use in surgery have expanded where guided surgery directed by fluorescence and near-infrared fluorescent imaging offers numerous advantages. Recently, surgeons have reported using ICG operative navigation in the emergency setting, with fluorescent cholangiography being the most common procedure. The utility of ICG also involves real-time perfusion assessment, such as ischemic organs and limbs. The rising use of ICG in surgery can be explained by the ICG's rapid technological evolution, accuracy, ease of use, and great potential to guide precision surgical diagnosis and management. The review aims to summarize the current literature on the uses of ICG in emergency general surgery. It provides a comprehensive and practical summary of the use of ICG, including indication, route of administration, and dosages. To simplify the application of ICG, we subdivided its use into anatomical mapping and perfusion assessment. Anatomical mapping includes the biliary tree, ureters, and bowel. Perfusion assessment includes bowel, pancreas, skin and soft tissue, and gonads. This review provides a reference to emergency general surgeons to aid in implementing ICG in the emergency setting for more enhanced and safer patient care.

Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients

Background: Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging. Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries. Bowel anastomosis after trauma-related resection is associated with a high rate of leakage. The ability of the surgeon’s bare eye to determine bowel viability remains limited, and the need for a more standardized objective assessment has not yet been fulfilled. Hence, there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize trauma-associated complications. Indocyanine green (ICG) coupled with fluorescence angiography is a potential solution for this problem. ICG is a fluorescent dye that responds to near-infrared irradiation. Methods: We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery. Discussion: ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance. However, there is a paucity of information regarding the use of this technology to treat traumas. Recently, angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions, leading to fewer cases of anastomotic insufficiency. This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety. However, there is no consensus on the ideal dose, time, and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings. Conclusions: There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection. This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’ operative care and safety in the field of trauma surgery.

Lighting the Way for Necrosis Excision Through Indocyanine Green Fluorescence-Guided Surgery

BACKGROUND

No objective technique exists to distinguish necrotic from viable tissue, risking over-excision in burns and loss of wound healing potential. Second window indocyanine green (SWIG) is a novel fluorescence-imaging modality being studied to identify residual solid tumors during oncological surgery. SWIG has also been shown to have avidity for necrosis in animal models, but translation of these findings to humans is lacking. The objective of this study was to evaluate SWIG in the identification of burn wound necrosis and compare it with previously published indocyanine green angiography (ICGA) techniques.

STUDY DESIGN

This study used mouse, human skin xenograft and human patient burn models. Brightfield and SWIG near-infrared imaging were performed on macroscopic tissue samples, which were then cryopreserved, sectioned, and analyzed for microscopic fluorescence. SWIG fluorescence findings were correlated to visual assessment of the burn wound as well as histological markers of necrosis using hematoxylin and eosin and lactate dehydrogenase stains.

RESULTS

We found that SWIG identified burn necrosis in a manner dependent on the dose and timing of indocyanine green (ICG) administration and had an inverse fluorescence signal compared with ICGA. Furthermore, SWIG fluorescence identified the interface of viable and nonviable tissue.

CONCLUSION

Our study confirmed that ICGA is an inconsistent and nonstandardized modality to evaluate burn injuries. In contrast, SWIG imaging is a potential imaging modality to objectively prognosticate burn wound healing potential and guide intraoperative burn excision. Further studies are needed to define ratios of fluorescence intensity values to guide surgical decision-making in burn excision and to better define how ICG is retained in necrotic tissue to enhance utility of SWIG in other disease processes.

The Role of ICG Angiography in Decision Making About Skin-Sparing in Pediatric Acute Trauma

BACKGROUND

Indocyanine green (ICG) angiography has proven useful in assessing skin flap perfusion in plastic and reconstructive surgeries. This research aimed to explore its role in decision making about skin-sparing in children's acute trauma.

METHODS

A total of 19 patients suffering with acute trauma from January 2019 to September 2021 were retrospectively assessed. Both ICG angiography and clinical judgment were performed to evaluate skin tissue viability. The intraoperative decisions for each case depended on the specific condition of the traumatic wound, including tissue perfusion, skin defect area, and location of the wound. Postoperative vascular imaging software was used to quantify the tissue perfusion, and the duration of postoperative follow-up was from 6 to 18 months.

RESULTS

Among them, 18 (94.7%) patients experienced treatments according to ICG angiography and did not develop postoperative necrosis. One case with right forearm trauma suffered from partial necrosis. Hypertrophic scar and local infection were the independent complications, which were managed by symptomatic treatment.

CONCLUSION

ICG angiography may reduce the risk of postoperative necrosis and renders a promising adjunctive technique for surgeons to make reasonable decisions in skin sparing in acute pediatric trauma.