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Time to maximum indocyanine green fluorescence of gastric sentinel lymph nodes and feasibility of combined indocyanine green/sodium fluorescein gastric lymphography

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Abstract

Purpose

Indocyanine green (ICG) and sodium fluorescein (SF) are fluorescent dyes used for sentinel lymph node mapping. In oncological gastric surgery, ICG lymphography has increased the number of resected lymph nodes. However, the optimal time to administer ICG is unclear, and both preoperative and intraoperative injections have been practised. As dye spillage will diminish lymphogram visibility, a second dye with different excitation and emission spectra may present a clinical alternative. We measured the time until maximum ICG fluorescence of gastric sentinel lymph nodes and investigated the feasibility of combined lymphography with two fluorescent dyes: ICG and SF.

Methods

Ten Danish Landrace/Yorkshire pigs were used in this study. After completion of the laparoscopic setup, ICG and then SF were endoscopically injected into the gastric submucosa. Lymphograms for both dyes were recorded, and the time until maximum ICG sentinel lymph node fluorescence was determined.

Results

The mean time until maximum ICG fluorescence of gastric sentinel lymph nodes was 50 s (± 12.5), and the fluorescent signal then remained stable until the end of the recorded period (45 min). A lymphogram showing both ICG and SF was acquired for eight of the ten pigs.

Conclusions

Because of the short time until maximum ICG fluorescence of sentinel lymph nodes, intraoperative injections could be a sufficient alternative to preoperative injections for oncological gastric surgery. Combined ICG and SF lymphography was feasible and resulted in clear lymphograms with no interference between the two dyes. The ability to use multiple dyes during a surgical procedure offers the exciting prospect of simultaneously assessing perfusion and performing fluorescence lymphography.

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Notes

  1. The light source (CLV-180 EVIS EXERA II; Olympus, Tokyo, Japan) emits narrowband wavelengths that excite SF. However, our laparoscope was an older model, which the light source did not “accept.” We thus modified (manually overrode) the light source to “accept” our laparoscope.

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Acknowledgements

We thank Mikkel Marquard Jessen, Anders Bech Jørgensen, Olivia Mortensen, August Olsen, Karina Adler Riemenschneider, Andreas Arendtsen Rostved, and Søren Roepstorff (Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Denmark) for their assistance with the surgical procedures. We would also like to thank the Department of Pathology (Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark) for their assistance with the tissue analyses.

Funding

The corresponding author received funding from the Department of Surgical Gastroenterology, Rigshospitalet research fund.

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Authors and Affiliations

  1. Oesophago Gastric Cancer Surgery Group (OGCS), Department of Surgical Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark

    Jens Osterkamp, Rune B. Strandby, Nikolaj Nerup, Lars Bo Svendsen & Michael Patrick Achiam

  2. Copenhagen Academy for Medical Education and Simulation (CAMES) – CAMES Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark

    Morten Bo Søndergaard Svendsen

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  1. Jens Osterkamp
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Contributions

Study conception and design: JO, RS, NN, MBS, LBS, MA. Acquisition of data: JO, RS, NN, MBS. Analysis and interpretation of data: JO, RS, NN, MBS, LBS, MA. Drafting of the manuscript: JO. Critical revision and final approval of the manuscript: JO, RS, NN, MBS, LBS, MA.

Corresponding author

Correspondence to Jens Osterkamp.

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Ethical approval

The study received approval from the Danish Animal Experiments Inspectorate (2019–15-0201–01664) and followed the Danish and European Union legislation on animal experimentation. It was supervised by research veterinarians at the Department of Experimental Medicine (The Panum Institute, University of Copenhagen, Copenhagen, Denmark).

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The authors declare no competing interests.

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Osterkamp, J., Strandby, R.B., Nerup, N. et al. Time to maximum indocyanine green fluorescence of gastric sentinel lymph nodes and feasibility of combined indocyanine green/sodium fluorescein gastric lymphography. Langenbecks Arch Surg 406, 2717–2724 (2021). https://doi.org/10.1007/s00423-021-02265-y

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