Use of fluorescence imaging and indocyanine green for sentinel node mapping during gastric cancer surgery: Results of an intercontinental Delphi survey

BACKGROUND

Understanding the extent of tumor spread to local lymph nodes is critical to managing early-stage gastric cancer. Recently, fluorescence imaging with indocyanine green has been used to identify and characterize sentinel lymph nodes during gastric cancer surgery, but no published guidelines exist. We sought to identify areas of consensus among international experts in the use of fluorescence imaging with indocyanine green for mapping sentinel lymph nodes during gastric-cancer surgery.

METHODS

In this 2-round, online Delphi survey, 27 international experts voted on 79 statements pertaining to patient preparation and contraindications to fluorescence imaging with indocyanine green during gastric cancer surgery; indications; technical aspects; advantages/disadvantages and limitations; and training and research. Methodological steps were adopted during survey design to minimize bias.

RESULTS

Consensus was reached on 61 of 79 statements, including giving single injections of indocyanine green into each of the 4 quadrants peritumorally, administering indocyanine green on the same day as surgery, injecting a total of 1 to 5 mL of 5 mg/mL indocyanine green, injecting endoscopically into submucosa, and repeating indocyanine green injections a second time if sentinel lymph node visualization remains inadequate. Consensus also was reached that fluorescence imaging with indocyanine green is an acceptable single-agent modality for sentinel lymph node identification and that the sentinel lymph node basin method is preferred. However, sentinel lymph node dissection should be limited to T1 gastric cancer and tumors ≤4 cm in diameter, and further research is necessary to optimize the technique and render fluorescence-guided sentinel lymph nodes dissection acceptable for routine clinical use.

CONCLUSION

Although considerable consensus was achieved, further research is necessary before this technology should be used in routine practice.

Fluorescence-guided surgery of the esophagus

The use of indocyanine green (ICG) fluorescence near-infrared (NIR) imaging during gastrointestinal surgery has surged in recent years. Its use in esophageal surgery is actively being studied both in the clinical setting and in the lab. NIR imaging has several important applications in esophageal surgery including assessing perfusion of the gastrointestinal-esophageal anastomosis, lymphatic drainage and tracheal blood flow after mediastinal dissection. This is a review of the modern literature summarizing the current knowledge on fluorescence-guided surgery of the esophagus.

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study

BACKGROUND

Our primary objective was to demonstrate the utility and feasibility of the intraoperative assessment of colon and rectal perfusion using fluorescence angiography (FA) during left-sided colectomy and anterior resection. Anastomotic leak (AL) after colorectal resection increases morbidity, mortality, and, in cancer cases, recurrence rates. Inadequate perfusion may contribute to AL. The PINPOINT Endoscopic Fluorescence Imaging System allows for intraoperative assessment of anastomotic perfusion.

STUDY DESIGN

This is a prospective, multicenter, open-label, clinical trial that assessed the feasibility and utility of FA for intraoperative perfusion assessment during left-sided colectomy and anterior resection at 11 centers in the United States.

RESULTS

A total of 147 patients were enrolled, of whom 139 were eligible for analysis. Diverticulitis (44%), rectal cancer (25%), and colon cancer (21%) were the most prevalent indications for surgery. The mean level of anastomosis was 10 ± 4 cm from the anal verge. Splenic-flexure mobilization was performed in 81% and high ligation of the inferior mesenteric artery in 61.9% of patients. There was a 99% success rate for FA, and FA changed surgical plans in 11 (8%) patients, with the majority of changes occurring at the time of transection of the proximal margin (7%). Overall morbidity rates were 17%. The anastomotic leak rate was 1.4% (n = 2). There were no anastomotic leaks in the 11 patients who had a change in surgical plan based on intraoperative perfusion assessment with FA.

CONCLUSIONS

PINPOINT is a safe and feasible tool for intraoperative assessment of tissue perfusion during colorectal resection. There were no anastomotic leaks in patients in whom the anastomosis was revised based on inadequate perfusion with FA.

Laparoscopic distal pancreatectomy

These authors conclude that laparoscopic distal pancreatectomy can be safely and effectively performed by surgeons skilled in basic laparoscopy and does not require specialized training or to be performed in a specialized center.

Background:

Laparoscopic management of distal pancreatic malignancies has been slow to gain a foothold in all but high-volume tertiary referral centers. The aim of this study was to assess the safety and outcomes of laparoscopic distal pancreatectomy (LDP) performed in a low-volume community hospital by a diverse group of surgeons, none of whom have a specialized laparoscopic background.

Methods:

We conducted a retrospective review of all patients who underwent open distal pancreatectomies (ODPs) and LDPs between August 2001 and June 2008. Data included type of surgery, open versus laparoscopy, demographics, operative time, blood loss, length of hospital stay, histopathologic diagnosis, postoperative complications, American Society of Anesthesiologists score, and mortality.

Results:

Twenty-seven patients with pancreatic masses underwent distal pancreatic resection during the study period. Fifty-nine percent (n = 16) underwent LDP, and 41% (n = 11) underwent ODP. Mean patient age was 66 y (range, 40 to 86) for the LDP group and 62 (range, 40 to 84) for the ODP group. Mean operative time was 231 min (range, 195 to 305) for LDP and 240 (range, 150 to 210) for the ODP technique. Mean length of stay for LDP and ODP was 8 (range, 3 to 22) and 12 d (range, 5 to 2), respectively. Morbidity was 25% (n = 4) in the LDP group and 36% (n = 4) in the ODP group. None of the differences between the LDP and ODP groups were statistically significant. No mortalities occurred in either group.

Conclusion:

This study supports the idea that LDP can be safely and effectively performed by any surgeon comfortable with basic laparoscopy and may not require specialized training or a specialized center. Further data are required to make more definitive conclusions.

Intra-operative transanal near infrared imaging of colorectal anastomotic perfusion: a feasibility study

AIM

Anastomotic dehiscence is a devastating complication. Inadequate blood supply is felt to be the prevailing cause. This study describes the use of near infrared imaging to evaluate transanally anastomotic tissue perfusion following low anterior resection.

METHOD

Twenty patients undergoing low anterior resection for benign and malignant disease were studied. After completing the anastomosis, indocyanine green (ICG) was injected via a peripheral intravenous catheter. An endoscopic near infrared imaging system (Pinpoint, Novadaq, Canada) was then used transanally to visualize mucosal perfusion of the colon, rectum and the anastomotic staple line.

RESULTS

All patients underwent a technically successful ICG angiogram. The angiogram was abnormal in four patients. Two of these had a protective loop ileostomy and showed no sign of anastomotic breakdown. The other two patients were found on CT scan to have a peri-anastomotic collection consistent with anastomotic leakage. Both were managed conservatively with resolution.

CONCLUSION

This study confirms that transanal ICG angiography is feasible and provides imaging of mucosal and anastomotic blood flow. The technique warrants further study in a larger group of patients to assess its ability to identify defects in tissue perfusion that may lead to anastomotic breakdown.

A novel adaptor converts a laparoscope into a high-definition rigid sigmoidoscope

The rigid sigmoidoscope is an important tool in a surgeon's armamentarium, yet it has remained essentially unchanged despite poor imaging and the inability to project or record the images. Herein we report our initial experience with a novel introducer built from readily available operating room supplies and designed to convert any standard laparoscope into a high-definition rigid sigmoidoscope.

Natural orifice translumenal endoscopic surgery inguinal hernia repair: a survival canine model

INTRODUCTION

With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model.

MATERIALS AND METHODS

Under general anesthesia with the animal in Trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed.

RESULTS

All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth.

DISCUSSION

This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.

Transitioning to single-incision laparoscopic inguinal herniorrhaphy

BACKGROUND

Laparoendoscopic single-site surgery (LESS) offers cosmetic benefits and may represent further progress towards reducing the invasiveness of surgical interventions. We report our initial experience with LESS totally extraperitoneal (TEP) inguinal herniorrhaphy.

MATERIALS AND METHODS

Beginning March 2009, we transitioned from a multiport laparoscopic TEP (MLH) technique to a single-incision TEP (SITE) technique. The first 52 consecutive patients who underwent SITE at our institution were compared with the preceding 52 MLH repairs.

RESULTS

Of the first 52 patients undergoing SITE, there were no conversions to either open or multiport surgery. The mean operative time for the SITE cases did not differ significantly from that of MLH. Complications were equivalent between the 2 groups and included postoperative seroma and urinary retention.

CONCLUSIONS

Transitioning from MLH to SITE was readily accomplished without significantly altering operative time or morbidity.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system

BACKGROUND

The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse.

METHODS

The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus.

RESULTS

Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve.

CONCLUSION

The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

BACKGROUND

A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported.

OBJECTIVE

Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH).

DESIGN

Feasibility study with a nonsurvival canine model.

INTERVENTIONS

Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 x 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed.

RESULTS

Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur.

LIMITATIONS

Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used.

CONCLUSIONS

Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

Posterior Prolapse: An Important Entity Even in the Modern Age of the Pars Flaccida Approach to Lap-Band Placement

BACKGROUND

The most prevalent long-term complications in patients who undergo laparoscopic adjustable gastric band (LAGB) surgery are pouch dilatation and gastric prolapse (slippage). Gastric prolapse can be divided into the anterior and posterior variety. Posterior prolapse is thought to be specific to the perigastric approach due to a lack of posterior band fixation. We report a series of 3 patients out of 1,104 who underwent LAGB placement using the pars flaccida approach and developed a posterior prolapse.

METHODS

Between March 2002 and December 2005, 1,104 patients underwent LAGB insertion using the pars flaccida approach at our institution. 3 patients (0.27%) developed posterior prolapse requiring reoperation.

RESULTS

All 3 patients presented with similar complaints, including solid food intolerance, gastroesophageal reflux and/or regurgitation. Although identical to those reported with anterior prolapse, diagnosis was definitively made with barium video esophagogram. All patients were treated with reoperation, but band replacement was impossible in 2 of the 3 cases secondary to extensive adhesion formation.

CONCLUSION

The finding of 3 patients who experienced posterior prolapse, despite using the pars flaccida approach, highlights the fact that this complication although diminished, has not been eliminated as previously thought. We describe the presentation, work-up, and management of this rare but important entity in the modern era of LAGB.