Near-infrared fluorescence-guided surgery using indocyanine green facilitates secure infrapyloric lymph node dissection
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ORIGINAL ARTICLE
Near‑infrared fluorescence‑guided surgery using indocyanine green facilitates secure infrapyloric lymph node dissection during laparoscopic distal gastrectomy Shin‑Hoo Park1 · Felix Berlth1,2 · Jong‑Ho Choi1 · Ji‑Hyeon Park1 · Yun‑Suhk Suh1 · Seong‑Ho Kong1 · Do Joong Park1 · Hyuk‑Joon Lee1,3 · Han‑Kwang Yang1,3 Received: 2 January 2020 / Accepted: 6 March 2020 © Springer Nature Singapore Pte Ltd. 2020
Abstract Purpose We aimed to investigate the usefulness of near-infrared indocyanine green (ICG)-enhanced fluorescence guidance for infrapyloric LN dissection in laparoscopic distal gastrectomy. Methods This study enrolled patients with early gastric cancer scheduled for laparoscopic distal gastrectomy. After intraoperative submucosal injection of ICG (0.1 mg/mL), LN dissection was conducted under near-infrared ICG fluorescence guidance. The operation time, bleeding events during infrapyloric LN dissection were analyzed. Cases were retrospectively 1:3 propensity-score matched to patients who underwent laparoscopic distal gastrectomy without ICG injection. Results The mean time from midline omentectomy to exposure of the right gastroepiploic vein was significantly shorter in the ICG group (n = 20) than in the non-ICG group (n = 60) (13.05 ± 5.77 vs 18.68 ± 7.92 min; p = 0.001), and the incidence of bleeding during infrapyloric LN dissection was lower in the ICG group (20% vs 68.3%, p 100 gastric surgeries per year.
Endpoints The primary endpoints were operation time and the incidence of bleeding events during infrapyloric LN dissection. For the purpose of evaluating operation time, the infrapyloric LN dissection procedure was evaluated in each of two stages, defined as follows: stage A, from midline
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omentectomy to RGEV exposure; stage B, from RGEV exposure to complete dissection of station #6. RGEV exposure was defined as follows: (a) The fat and lymphatics surrounding the RGEV have been peeled off, and both borders of the RGEV are visible with the vein-specific purple color; (b) If the contour of vein confluence is roughly shown by convergence of RGEV, (superior) right colic vein and anterior superior pancreaticoduodenal vein. The starting point of the midline omentectomy was defined as when the operator applied the energy device to open the gastrocolic ligament toward the duodenum after the assistant grasped the posterior wall of the stomach and retracted it to the cephalic/ splenic side (at 19s in Online Resource 1). The amount of intraoperative blood loss was measured separately for the two stages of infrapyloric LN dissection in the ICG group. Because we did not have blood loss data pertaining specifically to the infrapyloric LN dissection procedure in the non-ICG group, a gastric cancer surgeon, who was not participating as an operator, reviewed the video records to identify and define the bleeding events during infrapyloric LN dissection. Also, the bleeding event count during infrapyloric LN dissection assessed by video review was used as an alternative value for c
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