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Congenital chylothorax (CCT) and postoperative chylothorax (POCT) are rare and difficult to treat. We report our treatment strategy and outcomes for chylothorax, including thoracoscopic surgery with indocyanine-green (ICG) near-infrared fluorescence lymphangiography. A retrospective review of patients with CCT and POCT from 2014 to 2021 was performed. After definitive diagnosis, conservative treatments with octreotide, followed by intravenous steroids as needed, were performed. Patients who were refractory to conservative treatment were transferred to surgical treatment, consisting of thoracoscopic lymphatic leak ligations using ICG intraoperative lymphangiography. The effectiveness of conservative and surgical treatment was then examined. We included 19 cases of CCT and 31 cases of POCT. The 31 POCT patients included 23 of 84 postoperative patients with congenital diaphragmatic hernia (CDH), 7 of 54 postoperative patients with esophageal atresia (EA), and 1 of 3 postoperative patients with lymphatic malformation. The efficacy of conservative treatment was 12/19 for CCT, 22/23 for CDH, and 4/7 for EA. Surgical intervention was performed in 10 patients, and the rate of resolution of chylothorax within 3 weeks after surgery was 90%. Thoracoscopic lymphatic leak ligations with intraoperative ICG lymphangiography are feasible and useful in patients with chylothorax refractory to conservative treatment. Level IV • Chylothorax is rare and difficult to treat. • Although conservative treatment with octreotide is effective in many patients with chylothorax, some are refractory. • Thoracoscopic lymphatic leak ligations with intraoperative ICG lymphangiography are effective for refractory chylothorax. • Surgical intervention decisions could be made earlier than previously suggested. [ABSTRACT FROM AUTHOR]

Background: Near-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized. Methods: This survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons. Results: Survey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P <.001). Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption. Conclusions: NIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption. [ABSTRACT FROM AUTHOR]

Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the 'bipartite liver' is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital 'bipartite liver' associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy. [ABSTRACT FROM AUTHOR]

Objective: Compared to microscopes, exoscopes have advantages in field-depth, ergonomics, and educational value. Exoscopes are especially well-poised for adaptation into fluorescence-guided surgery (FGS) due to their excitation source, light path, and image processing capabilities. We evaluated the feasibility of near-infrared FGS using a 3-dimensional (3D), 4 K exoscope with nearinfrared fluorescence imaging capability. We then compared it to the most sensitive, commercially-available near-infrared exoscope system (3D and 960 p). In-vitro and intraoperative comparisons were performed. Methods: Serial dilutions of indocyanine-green (1-2000 µg/mL) were imaged with the 3D, 4 K Olympus Orbeye (system 1) and the 3D, 960 p VisionSense Iridium (system 2). Near-infrared sensitivity was calculated using signal-to-background ratios (SBRs). In addition, three patients with brain tumors were administered indocyanine-green and imaged with system 1, with two also imaged with system 2 for comparison. Results: Systems 1 and 2 detected near-infrared fluorescence from indocyanine green concentrations of >250 µg/L and >31.3 µg/L, respectively. Intraoperatively, system 1 visualized strong near-infrared fluorescence from two, strongly gadoliniumenhancing meningiomas (SBR=2.4, 1.7). The high-resolution, bright images were sufficient for the surgeon to appreciate the underlying anatomy in the near-infrared mode. However, system 1 was not able to visualize fluorescence from a weakly-enhancing intraparenchymal metastasis. In contrast, system 2 successfully visualized both the meningioma and the metastasis but lacked high resolution stereopsis. Conclusion: Three-dimensional exoscope systems provide an alternative visualization platform for both standard microsurgery and near-infrared fluorescent guided surgery. However, when tumor fluorescence is weak (i.e., low fluorophore uptake, deep tumors), highly sensitive near-infrared visualization systems may be required. [ABSTRACT FROM AUTHOR]

Introduction: Intraoperative fluorescence guidance is a well-established surgical adjunct in high-grade glioma surgery. In contrast, the clinical use of such dyes and technology has been scarcely reported in skull base surgery., Research Question: We aimed to systematically review the clinical applications of different fluorophores in both open and endonasal skull base surgery., Material and Methods: We performed a systematic review and discussed the current literature on fluorescence guidance in skull base surgery., Results: After a comprehensive literature search, 77 articles on skull base fluorescence guidance were evaluated. A qualitative analysis of the articles is presented, discussing clinical indications and current controversies. The use of intrathecal fluorescein was the most frequently reported in the literature. Beyond that, 5-ALA and ICG were two other fluorescent dyes most extensively discussed, with some experimental fluorophore applications in skull base surgery., Discussion and Conclusion: Intraoperative fluorescence imaging can serve as an adjunct technology in skull base surgery. The scope of initial indications of these fluorophores has expanded beyond malignant glioma resection alone. We discuss current use and controversies and present an extensive overview of additional indications for fluorescence imaging in skull base pathologies. Further quantitative studies will be needed in the future, focusing on tissue selectivity and time-dependency of the different fluorophores currently commercially available, as well as the development of new compounds to expand applications and facilitate skull base surgeries., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Eric Suero Molina reports a relationship with Carl Zeiss Meditec AG that includes: funding grants. Walter Stummer has received speaker and consultant fees from Medac, Carl Zeiss Meditec AG, Leica Microsystems, Photonamic, and NXDC and funding grants from Carl Zeiss Meditec AG. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Functioning to detect selective fluorescence in areas of increased permeability, near infrared (NIR) fluorescence imaging has emerged as a powerful adjunct in the field of surgical oncology. Here we present the first reported case of successful NIR in vivo and ex vivo visualization of a common peroneal nerve (CPN) schwannoma - a proof of concept for the novel use of intraoperative NIR fluorescent dyes for peripheral nerve tumor resection.

Background: Colonic perfusion is crucial for anastomotic healing and this could be evaluated intraoperatively using indocyanine-green fluorescence imaging (ICG FI). The aim of this study was to ascertain whether the use of ICG FI resulted in the reduction of anastomotic complications, i.e. AL and anastomotic stricture. Methods: Consecutive patients who underwent anterior resections or low anterior resections at our institution in the period from January 1st 2013 to December 31st 2018 were retrospectively reviewed. Surgery performed during the period from January 1st 2013 to December 31st 2015 did not involve the use of ICG FI (ICG−) while surgery during the period from January 1st 2016 to December 31st 2018 was performed with the use of ICG FI (ICG+). The anastomotic leakage rates of the two groups were compared after propensity score matching, taking into account the height of the anastomosis and any history of pelvic irradiation. Results: There was a total of 258 and 317 patients who had surgery with and without ICG FI, respectively. There were 253 patients in each group after propensity score matching. The overall anastomotic leakage rate was 3.6% and 7.9% for ICG+ and ICG−, respectively, (p = 0.035). Subgroup analysis showed that the use of ICG FI was significantly associated with a lower anastomotic leakage rate in total mesorectal excision (TME), 4.7% versus 11.6%, p = 0.043, but not in non-TME resections, 3.5% versus 2.4%, (p = 0.612). ICG FI, together with sex and anastomotic height, were independent predictors of anastomotic leakage. Conclusions: The routine use of ICG FI was associated with a lower anastomotic leakage rate in anterior resections. The reduction in anastomotic leakage rate was mainly seen in TME. [ABSTRACT FROM AUTHOR]

The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.

Background: Perfusion plays an important role in anastomotic healing. Indocyanine-green fluorescence angiogram allows objective bowel perfusion assessment. This study aimed to investigate the impact of perfusion assessment on intraoperative decision during left-sided colorectal resections.Method: This was a prospective, single-centre, observational study recruiting patients with left-sided colorectal resections. Perfusion of bowel segment was assessed with ICG fluorescence angiogram prior to resection and anastomosis intra-operatively. The planned transection site and the actual transection site after perfusion assessment were compared. The decision for diversion stoma was also evaluated.Results: 110 patients with cancer of the sigmoid colon (29.1%) and rectum (70.9%) were recruited. Total mesorectal excision was performed in 51.8% of patients. The transection site was revised in 34.5% of cases: 30.9% more proximally and 3.6% more distally. The median distance between the intended and actual transection sites was 2 cm (range 1-17 cm). A proximal revision in the transection site was more likely seen in rectal cancers (p = 0.036, OR 3.58, 95% CI 1.09-11.78) and relatively under-perfused left colon (p = 0.036, OR 1.01, 95% CI 1.01-1.02). Three (2.7%) patients were spared from a diversion stoma. The overall anastomotic leakage rate was 5.5%.Conclusion: ICG fluorescence angiogram altered operative decisions in a significant proportion of cases. The impact on transection site was more pronounced in patients with rectal cancers and those with relatively under-perfused colon. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and efficacy of embryologically based compartmental surgery for locoregional tumor control in intermediate and high risk endometrial cancer: peritoneal mesometrial resection with therapeutic pelvic and para-aortic lymphadenectomy by robotically assisted laparoscopy.Methods: 75 consecutive surgically treated patients with uterine malignancies have been analyzed. 68 patients with histologically proven endometrial cancer and complete robotically assisted surgery have been included in this study on morbidity and oncological outcome. 56 % of the patients were at intermediate/high risk with either stage IAG3 or IB (n = 22) or stage II-IV (n = 16). Adjuvant EBRT was offered to three patients only (4 %), whereas five received isolated vaginal brachytherapy (7 %). Indocyanine-green (ICG) fluorescence lymphography is demonstrated being useful for additional intraoperative visualization of the compartment borders and lymphatic drainage to the postponed lymph compartments.Results: After a mean follow-up of 32 months, there were only two loco-regional recurrences (2.9 %). Both recurrences were apparently cured by salvage therapy. 9 patients died; 6 (8.8 %) from metastatic disease (5) or unknown cause (1), 3 (4.4 %) from intercurrent disease without evidence of disease. One patient (1.4 %) experienced a peritoneal carcinosis and is alive. There were 8/68 perioperative complications (12 %). No perioperative mortality was observed.Conclusions: Embryologically defined compartmental surgery by robotically assisted laparoscopy seems to be feasible and safe in endometrial cancer. The low loco-regional recurrence rate of 2.9 % in spite of a very low percentage of adjuvant radiotherapy and 56 % of intermediate/high risk tumors should stimulate to initiate a multicentre trial to evaluate the value of compartmental surgery for prevention of locoregional recurrence in endometrial cancer. [ABSTRACT FROM AUTHOR]

Background & Aims: Ultrasonographic contrast agents allow the assessment of myocardial and renal perfusion through the analysis of refill kinetics after microbubbles rupture. This study evaluated the feasibility of contrast-enhanced ultrasonographic (CEUS) estimations of regional hepatic perfusion in patients with cirrhosis, and its correlation with clinical and hemodynamic parameters. Methods: Fifty-five patients with cirrhosis undergoing hepatic vein catheterization were included. Hepatic perfusion was studied by CEUS (using Contrast Coherent Imaging) during a continuous i.v. infusion of microbubbles (SonoVue®); after their rupture (high insonation power), tissue refill was digitally recorded and time-intensity curves were electronically calculated on a region of interest of the right hepatic lobe. Regional hepatic perfusion (RHP) was calculated as microbubbles velocity×microbubble concentration. During hepatic vein catheterization, we measured hepatic blood flow by indocyanine green (ICG) infusion, hepatic venous pressure gradient (HVPG), and cardiac output (Swan-Ganz catheter). Results: RHP was higher in patients than in healthy controls (5.1±3.7 vs. 3.4±0.7, p =0.003), and correlated with MELD (R =0.403, p =0.002), Child-Pugh score (R =0.348, p =0.009), and HVPG (R =0.279, p =0.041). RHP inversely correlated with ICG extraction (R =−0.346, p =0.039), ICG intrinsic clearance (R =−0.327, p =0.050), and ICG clearance (R =0.517, p =0.001), and directly correlated with hyperdynamic syndrome markers (cardiac index R =0.422, p =0.003; mean arterial pressure R =−0.405, p =0.004; systemic vascular resistance R =−0.496, p =0.001). Conclusions: RHP increases in patients with cirrhosis and correlates with the degree of liver failure and hyperdynamic syndrome. RHP increases along with liver functional reserve decrease, suggesting that RHP increase occurs mainly through anatomical/functional shunts. RHP by CEUS is a feasible novel, objective, quantitative, non-invasive tool, potentially useful for the estimation of hepatic perfusion in patients with cirrhosis. [Copyright &y& Elsevier]

• ICG-aPDT significantly reduced bleeding parameters in well and poorly controlled T2DM. • ICG-aPDT clinically reduced PD and gain in CAL in well and poorly controlled T2DM. • ICG-aPDT is suggestive to be more effective in periodontal wound healing in T2DM. : The aim of this randomized controlled clinical trial was to evaluate the efficacy of indocyanine-green mediated antimicrobial photodynamic therapy (ICG-aPDT) in the treatment of stage III grade C periodontitis in terms of clinical, microbiological, and immune-inflammatory parameters in patients with well-controlled and poorly-controlled form of type-2 diabetes mellitus (T2DM). : Subjects with a diagnosis of chronic periodontitis according to the new classification and case definition of periodontitis [probing depth (PD): ≥6 mm, interdental clinical attachment loss (CAL): ≥5 mm and bone loss extending to mid-third of root and beyond (≥3 mm)] were recruited. Subjects were grouped on the basis of well-controlled and poorly-controlled diabetic status. Two subgroups were made according to the treatment modality (RSD versus ICG-aPDT/RSD) in each group. A split-mouth design was used in which one site was designated for control (RSD alone treatment) while the other contralateral site was chosen for test treatment (ICG-aPDT/RSD) in all the patients. Periodontal parameters included the measurement of plaque score (PS), bleeding on probing (BOP), probing depth (PD), clinical attachment level (CAL) and alveolar bone levels (ABL). Identification of Porphyromonas gingivalis and Tannarella forsythia through PCR was executed using species specific primers. Gingival crevicular fluid samples were then analyzed using enzyme-linked immunosorbent assay for the quantification of interleukin (IL)-17 and interferon (IFN)-γ. All the clinical, microbiological, and immunological parameters were assessed using repeated measure ANOVA for intra and inter-group comparisons. The p-value significance was set at 0.05. : The mean age of the 50 patients was 44.7 ± 7.4 years. Systemic parameters suggest no significant change between the times in either HbA1c or serum CRP levels in any of the groups. A statistically significant reduction for BOP was noted for ICG-aPDT group for non-diabetic subjects at 3 months follow up only, while a significant reduction was seen at both 3 months and 6 months among well-controlled and poorly-controlled T2DM subjects (p <0.05). For PD and CAL, a significant improvement was seen for ICG-aPDT group among non-diabetic and well-controlled T2DM subjects at both 3- and 6-months follow up, while a significant reduction was seen at only 3 months among poorly-controlled T2DM subjects. A significant reduction was seen for ICG-aPDT group compared to RSD group for both bacteria in all the three groups at 6 months follow up (p <0.05). : ICG-aPDT significantly improved clinical and antimicrobial parameters in well-controlled and poorly-controlled T2DM having stage III and grade C periodontitis. Glycemic status did not have negative impact in the reduction of periodontal parameters in either types of T2DM. : The present RCT was registered in the clinicaltrials.gov under the identifier: NCT04857346 [ABSTRACT FROM AUTHOR]

• ICG-PDT significantly improved clinical peri‑implant parameters in DM. • ICG-PDT significantly reduced microbial species in periimplantitis with DM. • No change was seen with ICG-PDT for proinflammatory cytokines in DM. Background This 6-months randomized controlled clinical trial aimed to assess the efficacy of indocyanine green mediated photodynamic therapy (ICG-PDT) as an adjunct to peri‑implant manual debridement (PIMD) versus PIMD alone among Diabetes Mellitus (DM) patients in the treatment of peri‑implantitis. Methods A total of 48 DM patients having 64 implants were treated with either ICG-PDT + PIMD (n = 35 implants) or PIMD alone (n = 29 implants). Clinical (probing depth [PD], bleeding on probing [BOP], and plaque index [PI]) and radiographic (peri‑implant crestal bone loss [PCBL]) peri‑implant variables were recorded. Bacterial species including Porphyromonas gingivalis and Treponema denticola were evaluated from peri‑implant plaque biofilms. Levels of interleukin (IL)-1β and IL-6 were assessed after the collection of peri‑implant sulcular fluid. All the evaluations were carried out at baseline, 3- and 6-months. The significance level was set to p < 0.05. Results All clinical parameters significantly reduced within both treatment groups (P <0.05). Intra-group comparison indicates that there was statistically significant reduction in PD and suppuration for ICG-PDT group (P <0.05). There was a statistically significant difference in the BOP between ICG-PDT and PIMD groups at both follow-up periods (P <0.001). However, there was a significant difference for PD (P = 0.001), suppuration (P = 0.01), and PCBL (P = 0.04) on 6 months follow-up between ICG-PDT and PIMD groups, respectively. Only ICG-PDT showed a significant reduction in P. gingivalis and T. denticola on both 3 months and 6 months follow-up compared to baseline. PIMD showed a statistically significant reduction only on 3 months follow-up compared to baseline. This reduction was maintained for both the species when dental implants were treated with ICG-PDT. However, PIMD failed to maintain this reduction until 6 months. Only at 3 months assessment that both treatment groups showed statistically significant reduction in IL-1β and IL-6 with no significant difference between the groups. Both biomarkers failed to maintain the reduction in both groups and significantly increased levels for IL-1β was noted at 6 months follow up Conclusion Multiple application of indocyanine-green mediated photodynamic therapy resulted in improved clinical and microbial parameters among type 2 DM subjects in the treatment of peri‑implantitis. This clinical trial was registered in the ClinicalTrials.gov Protocol Registration and Results System with registration record number: NCT04833569 [ABSTRACT FROM AUTHOR]

Objective: To assess the factors that contribute to impaired quinine clearance in acute falciparum malaria. Patients: Sixteen adult Thai patients with severe or moderately severe falciparum malaria were studied, and 12 were re-studied during convalescence. Methods: The clearance of quinine, dihydroquinine (an impurity comprising up to 10% of commercial quinine formulations), antipyrine (a measure of hepatic mixed-function oxidase activity), indocyanine green (ICG) (a measure of liver blood flow), and iothalamate (a measure of glomerular filtration rate) were measured simultaneously, and the relationship of these values to the␣biotransformation of quinine to the active metabolite 3-hydroxyquinine was assessed. Results: During acute malaria infection, the systemic clearance of quinine, antipyrine and ICG and the biotransformation of quinine to 3-hydroxyquinine were all reduced significantly when compared with values during convalescence. Iothalamate clearance was not affected significantly and did not correlate with the clearance of any of the other compounds. The clearance of total and free quinine correlated significantly with antipyrine clearance ( r s = 0.70, P = 0.005 and r s = 0.67, P = 0.013, respectively), but not with ICG clearance ( r s = 0.39 and 0.43 respectively, P > 0.15). In a multiple regression model, antipyrine clearance and plasma protein binding accounted for 71% of the variance in total quinine clearance in acute malaria. The pharmacokinetic properties of dihydroquinine were generally similar to those of quinine, although dihydroquinine clearance was less affected by acute malaria. The mean ratio of quinine to 3-hydroxyquinine area under the plasma concentration-time curve (AUC) values in acute malaria was 12.03 compared with 6.92 during convalescence P=0.01. The mean plasma protein binding of 3-hydroxyquinine was 46%, which was significantly lower than that of quinine (90.5%) or dihydroquinine (90.5%). Conclusion: The reduction in quinine clearance in acute malaria results predominantly from a disease-induced dysfunction in hepatic mixed-function oxidase activity (principally CYP 3A) which impairs the conversion of quinine to its major metabolite, 3-hydroxyquinine. The metabolite contributes approximately 5% of the antimalarial activity of the parent compound in malaria, but up to 10% during convalescence. [ABSTRACT FROM AUTHOR]

Objectives The standard treatment for FIGO stage 1B1 cervical cancer is radical hysterectomy (RH) [1]. Indocyanine-green (ICG) is a drug injected within the cervical stroma to detect the sentinel lymph node (SLN) in cervical cancer [2,3]. ICG travels through the lymphatic channels in the lateral parametrium, which results enhanced with green, before reaching the SLNs. This could help identifying the surgical landmarks. The aim of this video is to propose a new approach to perform parametrial dissection as part of RH under the guidance of ICG. Methods The patient was a 49-years old woman diagnosed with a FIGO 1B1 moderately-differentiated cervical squamous cell carcinoma. No evidence of lymphoadenopathy on pre-operative imaging. 0.25 ml of ICG (1.25 mg/ml) were injected superficially and deep at 3 and 9 o'clock in the cervix as first step of the operation. Bilateral SLN biopsy followed by type C1 RH with bilateral salpingo-oophorectomy and bilateral pelvic node dissection was performed. Near-infrared camera (PINPOINT® - Novadaq Technologies) was used during parametrial dissection. Results ICG was used as a guide to demarcate the parametrial tissue and assist the dissection of the lateral (paracervix) and anterior (vesico-uterine ligament) parametrium off the surrounding structures (bladder and ureter). Operation time was 150 min and intraoperative estimated blood loss was 50 mls. No intraoperative or postoperative complication was reported. Conclusions ICG-assisted parametrial dissection during RH after SLN biopsy in early stage cervical cancer can be a useful tool to guide the surgeon to perform the procedure and potentially improve surgical outcomes. [ABSTRACT FROM AUTHOR]

The primary treatment for brain tumors often involves surgical resection for diagnosis, relief of mass effect, and prolonged survival. In neurosurgery, it is of utmost importance to achieve maximal safe resection while minimizing iatrogenic neurologic deficit. Thus, neurosurgeons often rely on extra tools in the operating room, such as neuronavigation, intraoperative magnetic resonance imaging, and/or intraoperative rapid pathology. However, these tools can be expensive, not readily available, time-consuming, and/or inaccurate. Recently, fluorescence-guided surgery has emerged as a cost-effective method to accurately visualize neoplastic areas in real-time to guide resection. Currently, 5-aminolevulinic-acid (5-ALA) remains the only fluorophore that has been approved specifically for fluorescence-guided tumor resection. Its use has demonstrated improved resection rates and prolonged progression-free survival. However, protoporphyrin-IX, the metabolic product of 5-ALA that accumulates in neoplastic cells, fluoresces in the visible-light range, which suffers from limited tissue penetration and significant auto-fluorescence. Near-infrared fluorescence, on the other hand, overcomes these problems with ease. Since 2012, researchers at our institution have developed a novel technique using indocyanine-green, which is a well-known near-infrared fluorophore used traditionally for angiography. This Second-Window-ICG (SWIG) technique takes advantage of the increased endothelial permeability in peritumoral tissue, which allows indocyanine-green to accumulate in these areas for intraoperative visualization of the tumor. SWIG has demonstrated utility in gliomas, meningiomas, metastases, pituitary adenomas, chordomas, and craniopharyngiomas. The main benefits of SWIG stem from its highly sensitive detection of neoplastic tissue in a wide variety of intracranial pathologies in real-time, which can help neurosurgeons both during surgical resections and in stereotactic biopsies. In this review of this novel technique, we summarize the development and mechanism of action of SWIG, provide evidence for its benefits, and discuss its limitations. Finally, for those interested in near-infrared fluorescence-guided surgery, we provide suggestions for maximizing the benefits while minimizing the limitations of SWIG based on our own experience thus far.

Objective: Intraoperative molecular imaging with tumor-targeted fluorescent dyes can enhance resection rates. In contrast to visible-light fluorophores (e.g., 5-aminolevulinic-acid), near-infrared (NIR) fluorophores have increased photon tissue penetration and less contamination from tissue autofluorescence. The second-window ICG (SWIG) technique relies on passive accumulation of indocyanine green (ICG) in neoplastic tissues. OTL38, conversely, targets folate receptor overexpression in nonfunctioning pituitary adenomas. In this study, we compare the properties of these 2 modalities for NIR imaging of pituitary adenomas to better understand the potential for NIR imaging in neurosurgery., Methods: A total of 39 patients with pituitary adenomas were enrolled between June 2015 and January 2018 in 2, sequential, IRB-approved studies. Sixteen patients received systemic ICG infusions 24 hours prior to surgery, and another 23 patients received OTL38 infusions 2-3 hours prior to surgery. NIR fluorescence signal-to-background ratio (SBR) was recorded during and after resection. Immunohistochemistry was performed on the 23 adenomas resected from patients who received OTL38 to assess expression of folate receptor-alpha (FRα)., Results: All 16 adenomas operated on after ICG administration demonstrated strong NIR fluorescence (mean SBR 4.1 ± 0.69 [SD]). There was no statistically significant difference between the 9 functioning and 7 nonfunctioning adenomas (p = 0.9). After administration of OTL38, the mean SBR was 1.7 ± 0.47 for functioning adenomas, 2.6 ± 0.91 for all nonfunctioning adenomas, and 3.2 ± 0.53 for the subset of FRα-overexpressing adenomas. Tissue identification with white light alone for all adenomas demonstrated 88% sensitivity and 90% specificity. SWIG demonstrated 100% sensitivity but only 29% specificity for both functioning and nonfunctioning adenomas. OTL38 was 75% sensitive and 100% specific for all nonfunctioning adenomas, but when assessment was limited to the 9 FRα-overexpressing adenomas, the sensitivity and specificity of OTL38 were both 100%., Conclusions: Intraoperative imaging with NIR fluorophores demonstrates highly sensitive detection of pituitary adenomas. OTL38, a folate-receptor-targeted fluorophore, is highly specific for nonfunctioning adenomas but has no utility in functioning adenomas. SWIG, which relies on passive diffusion into neoplastic tissue, is applicable to both functioning and nonfunctioning pituitary adenomas, but it is less specific than targeted fluorophores. Thus, targeted and nontargeted NIR fluorophores play important, yet distinct, roles in intraoperative imaging. Selectively and intelligently using either agent has the potential to greatly improve resection rates and outcomes for patients with intracranial tumors.

Background Giant serpentine aneurysms are a rare entity, which can be managed using either endovascular or surgical techniques. Although the perioperative morbidity and mortality have decreased since the development of bypass revascularization procedures, their surgical treatment is still challenging. Intraoperative functional and perfusion monitoring techniques can be precious to make better decisions and improve outcomes. Case Description We report on the case of a giant, unruptured, partially thrombosed, serpentine middle cerebral artery aneurysm that was treated with partial endovascular coiling of intra-aneurysmal vascular channels, surgical resection of the aneurysm, and end-to-end M1-temporal M2 anastomosis. Conclusions Intraoperative continuous motor evoked potentials monitoring, flowmetry, and indocyanine-green angiography provide precise and reproducible information about cerebral function and perfusion, respectively, allowing for more rational decision making during surgery for these challenging malformations. [ABSTRACT FROM AUTHOR]