Appropriate lymphatic assessment is a cornerstone of definitive surgical resection for colorectal cancer. Near-infrared (NIR) laparoscopy may allow real-time intraoperative identification of territorial lymphatic drainage and sentinel nodes in patients with early-stage disease prior to radical basin resection.
With IRB approval and individual consent, consecutive patients with radiologically localized neoplasia underwent peritumoral submucosal injection of indocyanine green (ICG, a fluorophore capable of injection site tattooing and efferent lymphatic migration) prior to standard laparoscopic oncological resection. Intraoperatively, a prototype NIR laparoscope provided both white light and, by switch activation, NIR irradiation with or without discrete spectral back-filtration. Fluorescence identification of sentinel nodes prior to formal specimen dissection allowed their identification for separate histopathological analysis by in situ clipping when found within the specimen or selective lymphadenectomy by “berry-picking” when such nodes lay outside of the standard resection field. Concordance with nonsentinel nodes was then analysed.
Eighteen patients (mean age = 66.4 years [range = 47.9–80.1], mean BMI = 29.1 [range = 20.0–39.9]) were studied. Fourteen had biopsy-proven carcinoma and four had endoscopically unresectable dysplasia. Mesocolic sentinel nodes (mean = 4.1/patient) were rendered obvious by fluorescence either solely within the standard resection field (n = 14) or both within and without the planned field (n = 4) within minutes of dye injection in every case. Laparoscopic ultrasound (n = 5) as well as histopathological analysis demonstrated oncologic correlation of mesocolic sentinel with corresponding territory nonsentinel nodes, correctly confirming the presence of mesocolic disease in 3 patients and the absence of such lymphatic spread in the remaining 15 patients.
In this study, NIR laparoscopy with ICG mapping allowed ready and rapid confirmation of mesocolic lymphatic drainage patterns and sentinel node identification. With further validation, this technology and technique promises precise, tailored resection surgery by indicating basin pattern and status in advance of radical lymphadenectomy.
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Ronan Cahill received the Career Development Award from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) for the purpose of advancing this work. In addition, all authors gratefully acknowledge the support of the Oxford Colon Cancer Trust (OCCTOPUS) and the Pharsalia Trust. The laparoscopic NIR system was provided under an unrestricted use agreement from Olympus, with the first author acting as consultant for the company from this perspective. No right of review of the data or manuscript was requested or provided. The authors greatly appreciate the interest and support of Mr. Glynn Burt and Mr. Ian Bennett (Olympus UK), Mr. Manocher Ganghlosi and Mr. Hulbert Baltes (Olympus Europa), and Mr Taniguchi (Olympus Tokyo). The authors also recognize the endeavour and contributions of Mr. Shaqil Ahmed, Dr. James East, Mr. Bruce George, Mr. Richard Guy, Mr. Roel Hoempes, and Mr. Oliver Jones in addition to those of Ms. Lian Lee, RN, and all of the Colorectal Department, Oxford Radcliffe Hospitals.
The laparoscopic NIR system was provided under an unrestricted use agreement from Olympus with Dr. Cahill acting as consultant for the company from this perspective. Drs. Anderson, Wang, Lindsey, Cunningham, and Mortensen have no conflicts of interest or financial ties to disclose.
Electronic supplementary material
Below is the link to the electronic supplementary material.
ICG injection technique by on-table sigmoidoscopy at the time of definitive laparoscopic resection (WMV 2568 kb)
NIR laparoscopic images in the same patient in Video 1 (WMV 80968 kb)
Further NIR laparoscopic images in another patient illustrating ICG tracing to the lateral iliac nodes (WMV 25896 kb)
Further case showing NIR laparoscopic images in a patient who underwent peritumoral ICG injection 24 h preoperatively (WMV 2817 kb)
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Cahill, R.A., Anderson, M., Wang, L.M. et al. Near-infrared (NIR) laparoscopy for intraoperative lymphatic road-mapping and sentinel node identification during definitive surgical resection of early-stage colorectal neoplasia. Surg Endosc 26, 197–204 (2012). https://doi.org/10.1007/s00464-011-1854-3
- Laparoscopic colorectal cancer surgery
- Early-stage colorectal cancer
- Near-infrared (NIR) laparoscopy
- Indocyanine green (ICG)
- Lymphatic mapping
- Sentinel node biopsy