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Laparoscopic total gastrectomy (LTG) for remnant gastric cancer (RGC) requires advanced techniques due to severe postoperative adhesions and anatomic changes. We performed LTG in 2 patients with RGC using intraoperative indocyanine green (ICG) fluorescence imaging. Both cases previously underwent distal gastrectomy with Billroth-I reconstruction for gastric cancer and were subsequently diagnosed with early-stage gastric cancer of the remnant stomach. Indocyanine green (2.5 mg/body) was administered intravenously during surgery. The liver and common bile duct were clearly visualized during surgery using near-infrared fluorescence laparoscopy, and the adhesions between the hepatobiliary organs and remnant stomach were safely dissected. Laparoscopic total gastrectomy was successfully performed without complications, and the postoperative course was uneventful in both cases. Intraoperative real-time ICG fluorescence imaging allows clear visualization of the liver and common bile duct and can be useful in LTG for RGC with severe adhesions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This preliminary study is the first to demonstrate that AI can precisely identify loose connective tissue during laparoscopic cholecystectomy and ICG fluorescent cholangiography. Tashiro and colleagues conclude that this novel real-time navigation modality fusing AI and ICG fluorescent imaging may enhance safety and provide more reliable laparoscopic or robotic surgery., (© 2024 Japanese Society of Hepato‐Biliary‐Pancreatic Surgery.)

Background/aim: Radiofrequency ablation (RFA) is used to treat primary and metastatic tumors in the liver. However, local recurrence after RFA is frequent and subsequent salvage hepatectomy is often ineffective due to difficulty in visualization of tumor margins., Patients and Methods: In the present retrospective clinical trial, seven patients from the Department of General and Gastro-enterological Surgery, Showa University School of Medicine underwent salvage hepatectomy for recurrent hepatocellular carcinoma (HCC) (n=2), colorectal liver metastasis (n=4) and lung-carcinoid liver metastasis (n=1), after RFA, between 2011 and 2020. Tumors were labeled with indocyanine green (ICG) and resected under fluorescence guidance. Resected specimens were evaluated under fluorescence microscopy as well as by standard histopathological techniques., Results: Pathological findings revealed negative tumor margins in all patients after fluorescence-guided surgery. Six of seven resected tumors had a fluorescent rim, including both HCC and liver metastasis. Fluorescence microscopy demonstrated that viable cancer tumor cells were located only on the inside of the fluorescent rim, and no malignant cells were detected within the fluorescent rim surrounding the tumor. Fluorescence microscopy showed that the tumor margin was secured if the fluorescence signal was completely resected., Conclusion: The present results demonstrate that ICG labeling of liver tumors recurring after RFA enabled complete resection under fluorescence guidance. The present study is the first clinical study to demonstrate that tumor types that generally cannot be completely resected with bright light are fully resectable under fluorescence guidance., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To establish consensus recommendations for the use of fluorescence imaging with indocyanine green (ICG) in hepatobiliary surgery., Background: ICG fluorescence imaging has gained popularity in hepatobiliary surgery in recent years. However, there is varied evidence on the use, dosage, and timing of administration of ICG in clinical practice. To standardize the use of this imaging modality in hepatobiliary surgery, a panel of pioneering experts from the Asia-Pacific region sought to establish a set of consensus recommendations by consolidating the available evidence and clinical experiences., Methods: A total of 13 surgeons experienced in hepatobiliary surgery and/or minimally invasive surgery formed an expert consensus panel in Shanghai, China in October 2018. By the modified Delphi method, they presented the relevant evidence, discussed clinical experiences, and derived consensus statements on the use of ICG in hepatobiliary surgery. Each statement was discussed and modified until a unanimous consensus was achieved., Results: A total of 7 recommendations for the clinical applications of ICG in hepatobiliary surgery were formulated., Conclusions: The Shanghai consensus recommendations offer practical tips and techniques to augment the safety and technical feasibility of ICG fluorescence-guided hepatobiliary surgery, including laparoscopic cholecystectomy, liver segmentectomy, and liver transplantation., Competing Interests: The authors declare no conflict of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background/aim: Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) is used to visualize colon-cancer liver metastases (CCLM) during surgery. The present study aimed to use ICG to visualize small CCLM in an orthotopic mouse model., Materials and Methods: A 3-mm fragment of HT29 human colon cancer was implanted to the liver of 5 athymic nude mice (nu/nu). The Pearl Trilogy Small Animal Fluorescence Imaging system was used 24 h after intravenous (IV) injection of 0.025 mg (0.25 mg/ml) ICG., Results: In four of the five mice, tumor fluorescence was detected. Small tumors (approximately 3 mm) were distinctly visualized with a minimal fluorescence liver signal, with a mean tumor to liver signal ratio of 1.81 (SD±0.167)., Conclusion: Small CCLM can be clearly identified by ICG fluorescence in an orthotopic nude-mouse model. This model is translatable to the clinic for the detection of occult early CCLM., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Preoperative imaging is widely used and extremely helpful in hepatobiliary surgery. However, transfer of preoperative data to a intraoperative situation is very difficult. Surgeons need intraoperative anatomical information using imaging data for safe and precise operation in the field of hepatobiliary surgery. We have developed a new system for mapping liver segments and cholangiograms using intraoperative indocyanine green (ICG) fluorescence under infrared light observation., Method: The imaging technique for mapping liver segments and cholangiogram based on ICG fluorescence used an infrared-based navigation system. Eighty one patients with liver tumors underwent hepatectomy from 2006, January to 2009, March. In liver surgery, 1 ml of ICG was injected via the portal vein under observation by the fluorescent imaging system. Fourteen patients were underwent laparoscopic cholecystectomy for chronic cholecystitis with gallstones. In laparoscopic cholecystectomy, 5 ml of ICG was administered intravenously just before operation and the bile duct was observed using the infrared-based navigation system., Result: This new technique successfully identified stained subsegments and segments of the liver in 73 of 81 patients (90.1%). Moreover, clear mapping of liver segments was obtained even against a background of liver cirrhosis. Fluorescent cholangiography clearly showed the common bile duct and cystic duct in 10 of 14 patients (71.4%). No adverse reactions to the ICG were encountered., Conclusion: Application of this technique allows intraoperative identification of anatomical landmark in hepatobiliary surgery.

Objective: In this study, we determined the possible usefulness of sentinel node (SN) mapping guided by indocyanine green (ICG) fluorescence imaging in the management of gastric cancer., Summary Background Data: ICG fluorescence imaging system has recently been developed for obtaining biochemical information from living tissues., Methods: Our series consisted of 56 patients with gastric cancer who underwent standard gastrectomy with lymphadenectomy. Two milliliters of ICG solution (0.5%) was injected into the submucosa around the tumor endoscopically before the operation or into the subserosa intraoperatively. ICG fluorescence imaging was conducted using a charge-coupled device camera with a light-emitting diode having a wavelength of 760 nm as the light source and a cut filter to filter out light with wavelengths below 820 nm as the detector., Results: SNs were detected in 54 (96.4%) of the 56 patients, and the mean number of SNs was 7.2 +/- 7.0. Even SNs that were not green in color could be easily and clearly visualized by ICG fluorescence imaging. cT1-stage cancers were associated with a significantly higher accuracy rate (97.2% vs. 72.2%, P = 0.0127) than cT2-or cT3-stage cancers. Preoperative ICG injection was associated with a significantly higher incidence of cT1-stage cancers (87.1% vs. 40.0%, P = 0.0004), a larger mean number of SNs (9.9 +/- 7.5 vs. 4.1 +/- 5.0, P < 0.0001), a higher accuracy rate (100% vs. 73.9%, P = 0.0039), and a lower false negative rate (0% vs. 60.0%, P = 0.0345) as compared with intraoperative ICG injection., Conclusions: This study shows that ICG fluorescence imaging allows highly sensitive image-guided intraoperative SN mapping in cases of gastric cancer. Our data suggest that SN mapping guided by ICG fluorescence imaging might be useful for predicting the metastatic status in lymph nodes in cases of gastric cancer, especially those with cT1-stage cancer.

Background: In malignant hepatic neoplasm, anatomic resection could improve survival and limit complications from hepatectomy. Our purpose was to develop an intraoperative method for identifying segment and subsegment of the liver with high-sensitivity near-infrared fluorescence imaging., Methods: The subjects were 35 patients with hepatic malignant liver disease who received hepatectomy in 2006. The segments of liver method of identification that used infrared observation camera system termed Photo Dynamic Eye-2 (PDE-2) with indocianine green (ICG) for the patient with malignant liver tumor (hepatocellular carcinoma: 13 cases; metastatic liver cancer: 18 cases; intrahepatic cholangio carcinoma: 4 cases) were performed before liver resection., Results: Although greenish stain of the liver surface after the injection of ICG via portal vein is not visible clearly without infrared observation camera system PDE-2, 1 minute after injection of ICG with fluorescent using infrared observation camera system PDE-2, demarcation of liver segment and subsegment was clearly detected. Ten minutes after injection of ICG with fluorescent using infrared observation camera system PDE-2, fluorescence of liver subsegment remained. Stained subsegment and segment of liver were identifiable in 33 (94.3%) of the 35 patients. There were no complications or side-effects related to the injection of patent blue dye., Conclusion: We demonstrated here that near-infrared fluorescence imaging system is a novel and reliable intraoperative technique to identify hepatic segment and subsegment for anatomical hepatic resection.

Indocyanine green fluorescence imaging (ICG-FI)—a sensitive tool for detecting tumor localization in laparoscopic surgery—produces false positive results for benign liver tumors. This report is the first case of hepatic angiomyolipoma (HAML) treated laparoscopically with ICG-FI. We present the case of a 31-year-old woman with a liver tumor that was a 13-mm mass in the anterior superior segment. Though a benign tumor was suspected, malignant potential could not be ruled out. Therefore, minimally invasive laparoscopic resection using ICG-FI was planned. ICG, intravenously injected preoperatively, revealed the tumor's existence. Pure laparoscopic hepatectomy with ICG-FI was performed for excisional biopsy, during which the tumor was resected with adequate surgical margins, followed by histological confirmation of HAML. In conclusion, it is suggested that laparoscopic resection with ICG-FI is an effective minimal invasive surgery for tumors that are difficult to detect, such as HAML, leading to a safe surgical margin. [ABSTRACT FROM AUTHOR]

Purpose: Bile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries. Patients and Methods: We examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively. Results: There were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50– 197) minutes, and estimated blood loss was 43.2 (0– 400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3– 9) days, and no postoperative complications (Clavien–Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely. Conclusion: ICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate the feasibility of the PINPOINT® Endoscopic Fluorescence Imaging System (PINPOINT) for intraoperative identification of colonic tumor sites during laparoscopic colorectal surgery. Methods: Eighty consecutive patients with colorectal cancer were prospectively enrolled. Preoperatively, 0.5 mL of indocyanine green (ICG; 2.5 mg/mL) was injected into the submucosal space only at the distal side of the tumor under colonoscopy. Intraoperatively, we identified the tumor site on a PINPOINT image in which near-infrared fluorescence was superimposed in pseudocolor on a white light image. We estimated the intraoperative visibility rate of the tumor site and safety of ICG injection and assessed the interobserver variability of visibility grade between 2 surgeons. Results: The intraoperative visibility rate of the tumor site was 93.8% (75/80). The visibility rate at an interval between injection and surgery of <7 days was significantly better than that at an interval of ≥ 10 days ( p < 0.001). The kappa value between 2 observers was 0.827 (95% CI 0.635-1.019) with an agreement rate of 92.5%. There were no preoperative adverse reactions to ICG or intraoperative complications. Conclusions: Using ICG with the PINPOINT for identifying colonic tumor sites was feasible without any adverse effects during laparoscopic colorectal surgery. [ABSTRACT FROM AUTHOR]