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Intraoperative near-infrared lymphography with indocyanine green may aid lymph node dissection during robot-assisted resection of gastroesophageal junction cancer

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Abstract

Background

Adequate lymphadenectomy during gastroesophageal junction (GEJ) cancer resection is essential, because lymph node (LN) metastasis correlates with increased recurrence risk. Fluorescence lymphography with indocyanine green (ICG) has been used for LN mapping in several surgical specialties; however, reports on GEJ cancer are lacking. Therefore, we investigated whether intraoperative ICG lymphography could facilitate LN harvest during robot-assisted resection of GEJ cancer.

Methods

Patients scheduled for robot-assisted resection of GEJ cancer were included, and outcomes were compared with historical controls. After intraoperative endoscopic submucosal ICG injection, standard D1 + LN dissection was performed under white light. Then, near-infrared (NIR) fluorescence imaging was activated, and each LN dissection area was re-examined. Any tissue within the D1 + field exhibiting distinctly increased ICG fluorescence compared with background tissue was dissected and sent for pathology review.

Results

We included 70 patients between June 2020 and October 2021. Three cases were aborted due to disseminated disease, and two were converted to open resection and excluded from the analysis. Additional tissue was dissected after NIR review in 34 of 65 (52%) patients. We dissected 43 fluorescent tissue samples, and after pathology review, 30 were confirmed LNs; none were metastatic. The median number of LNs harvested per patient (34, interquartile range [IQR] = 26–44) was not significantly different from that harvested from historical controls (32, IQR = 24–45; p = 0.92), nor were there any differences between these two groups in the duration of surgery, intraoperative blood loss, or comprehensive complication scores (p = 0.12, p = 0.46, and p = 0.41, respectively).

Conclusions

Intraoperative NIR lymphography with ICG may aid LN detection during robot-assisted resection of GEJ cancer without increasing surgical risk. Although NIR lymphography may facilitate LN dissection, none of the LN removed after the NIR review was metastatic. Hence, it remains uncertain whether NIR lymphography will improve oncological outcomes.

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Acknowledgements

The authors sincerely thank all participating surgeons, anesthesiologists, and nurses from the Surgical Gastroenterology and Anesthesia departments at Rigshospitalet, Copenhagen for their most valuable contributions.

Funding

The corresponding author received funding from Medtronic plc (Grant: OPI-projekt), Grosserer L.F. Foghts Fond (Grant Number: 21807), Fabrikant Einar Willumsens Mindelegat (Grant Number: 500028) and Aase og Ejnar Danielsens Fond (No grant number was provided).

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Authors and Affiliations

  1. OesophagoGastric Cancer Surgery Group (OGCS), Department of Surgery and Transplantation, Rigshospitalet, University Hospital of Copenhagen, Inge Lehmanns Vej 7, 2100, Copenhagen Ø, Denmark

    Jens Osterkamp, Rune Strandby, Nikolaj Nerup, Lars-Bo Svendsen & Michael Achiam

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

    Morten-Bo Svendsen

Authors
  1. Jens Osterkamp
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  2. Rune Strandby
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  3. Nikolaj Nerup
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  4. Morten-Bo Svendsen
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  5. Lars-Bo Svendsen
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  6. Michael Achiam
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Corresponding author

Correspondence to Jens Osterkamp.

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Disclosures

Jens Osterkamp received funding from Medtronic plc (Grant: OPI-projekt), Grosserer L.F. Foghts Fond (Grant Number: 21807), Fabrikant Einar Willumsens Mindelegat (Grant Number: 500028), and Aase og Ejnar Danielsens Fond (No Grant Number was provided). Rune Strandby, Nikolaj Nerup, Morten Bo Søndergaard Svendsen, Lars Svendsen, and Michael P. Achiam have no conflicts of interest or financial ties to disclose.

Ethical approval

The study was approved by the Danish Committee on Health Research Ethics (ID: H-19041735) and registered at clinicaltrials.gov (ID: NCT04107623). Approval to retrieve and compare data from historical controls was received from the Centre of Regional Development, Capital Region of Denmark (R-21049798).

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Osterkamp, J., Strandby, R., Nerup, N. et al. Intraoperative near-infrared lymphography with indocyanine green may aid lymph node dissection during robot-assisted resection of gastroesophageal junction cancer. Surg Endosc 37, 1985–1993 (2023). https://doi.org/10.1007/s00464-022-09684-y

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