Application of Near-Infrared Fluorescence Imaging with Indocyanine Green in Totally Laparoscopic Distal Gastrectomy

Abstract

Purpose: Recently, totally laparoscopic gastrectomy has been gradually accepted by surgeons worldwide for gastric cancer treatment. Complete dissection of the lymph nodes and the establishment of the surgical margin are the most important considerations for curative gastric cancer surgery. Previous studies have demonstrated that indocyanine green (ICG)-traced laparoscopic gastrectomy significantly improves the completeness of lymph node dissection. However, it remains difficult to identify the tumor location intraoperatively for gastric cancers that are staged ≤T3. Here, we investigated the feasibility of ICG fluorescence for lymph node mapping and tumor localization during totally laparoscopic distal gastrectomy.

Materials and methods: Preoperative and perioperative data from consecutive patients with gastric cancer who underwent a totally laparoscopic distal gastrectomy were collected and analyzed. The patients were categorized into the ICG (n=61) or the non-ICG (n=75) group based on whether preoperative endoscopic mucosal ICG injection was performed.

Results: The ICG group had a shorter operation time and less intraoperative blood loss. Moreover, significantly more lymph nodes were harvested in the ICG group than the non-ICG group. No pathologically positive margin was found and there was no significant difference in either the proximal or distal surgical margins between the 2 groups.

Conclusions: Near-infrared fluorescence imaging with ICG can be successfully used in totally laparoscopic distal gastrectomy, and it contributes to both the completeness of D2 lymph node dissection and confirmation of the gastric transection line. Well-designed prospective randomized studies are needed in the future to fully validate our findings.

Keywords: Gastrectomy; Gastric cancer; Indocyanine green; Lymph node dissection; Tumor.

Conflict of interest statement

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Copyright © 2020. Korean Gastric Cancer Association.

Figures

Fig. 1. Endoscopic findings of ICG injection. (A) The tumor lesion was located by preoperative endoscopy (white arrow); (B) ICG was injected into the submucosal layer of gastric cancer region at 4 points: proximal, distal, and 2 bilateral points.

ICG = indocyanine green.

Fig. 2. Lymphadenectomy with near infrared fluorescent navigation. (A) Dissection of No. 8 lymph node; (B) dissection of No. 6 lymph node.

Fig. 3. Intraoperative confirmation of surgical margin. (A) Diameter of the proximal injection point (maximum length along the longitudinal axis of stomach) was measured laparoscopically; (B) 5-d/2 (d = maximum length along the longitudinal axis of stomach) from proximal injection point edge was recognized as the transection line; (C) confirmation of surgical margin after removal of specimen under NIR-activated ICG; (D) surgical margin of the inner stomach wall was confirmed under NIR-activated ICG.

NIR = near infrared; ICG = indocyanine green.