Fluorescent insicionless cholangiography during laparoscopic cholecystectomy. Is this a New Gold Standard?
This presentation is aimed to reinforce the impact of this novel technology that might transform Laparoscopic Cholecystectomy into one of the safest surgical procedures. Despite the major advances in Laparoscopic Cholecystectomy over the past two decades, patients undergoing the procedure may still face life-threatening complications due to misidentification of the bile duct anatomy.
With the routine use of near infrared (NIR) guided surgery, surgeons have the possibility to increase the range of visualization and understanding of the extrahepatic bile ducts and avoid injuries due to misidentification. This lecture will provide a clear understanding of the basic principles of this novel and simple technique. In addition, there will be an opportunity to learn surgical tips and review the most important data from the literature.
Raul J. Rosenthal, MD, FACS, FASMBS
Director Professor of Surgery and Chairman, Department of General Surgery Director, General Surgery Residency Program Director, The Bariatric and Metabolic Institute Cleveland Clinic Florida Co-Editor in Chief, Surgery for Obesity and Related Diseases President, South Florida Chapter of the American College of Surgeons
Endocrine procedures like thyroidectomies and adrenalectomies are commonly performed by general and endocrine surgeons around the world. Unfortunately during the surgeries patients might be at risk of suffering complications like hypocalcemia after thyroidectomies due to parathyroid glands injuries, or bleeding during a laparoscopic adrenalectomies to difficulties during adrenal vessels identification. An accurate visualization of the glands like parathyroid glands, tumors or adrenal glands are key steps in order to perform a safe procedure. In the last years the use of fluorescence allowed surgeons to better understand the anatomy and visualize the localization and vascularization of the glands avoiding complications. The audience will be able to understand the basic concepts of the method and to learn technical tips of the technology. A literature review of clinical outcomes in endocrine fluorescence guided surgery will be performed.
Fernando D. Dip, MD
Staff Surgical Oncology, Hospital de Clínicas Buenos Aires Chief of Surgical Reaseach, University of Buenos Aires Affiliated Surgeon, Cleveland Clinic Florida
Anastomotic leak is one of the most feared complications in colorectal surgery, with significant resultant morbidity and mortality. Etiologies of anastomotic leaks are varied, multifactorial, and have been well described in the literature (C01, C02). Several methods have been described in the quest to minimize rates of anastomotic leak in colorectal surgery; the most promising technology is definitely the real-time intraoperative perfusion assessment of the anastomosis using fluorescence angiography (C03, C04).
Table 1 summarizes most of the major studies evaluating colorectal anastomosis perfusion using ICG based fluorescence angiography. (Table 1)
There are a variety of NIR systems currently on the market, however all of them have been shown to be accurate and with technical success approaching 100% in most publications.
The dosage of ICG that has been reported varies significantly between different publications and ranges from 3.75-10mg or in the range of in the range of 0.1–0.3 mg/kg. However, the dose administered has not affected the technical success of the fluorescence angiography, and probably is not of significant importance as the maximal safe dose of ICG (2 mg/kg) has not been administered. Use of ICG based fluorescence angiography is perhaps surprisingly safe with no significant adverse effects reported.
Review of the current literature regarding perfusion assessment in colorectal surgery demonstrates that fluorescence angiography is usually associated with low rates of anastomotic leak. As shown in table 1, the combined average leak rate in more than 2000 patients who underwent fluorescence angiography 2.9%, and change in surgical plans (mainly change in resection point) happened in 9.4% of the patients.
There was one major multicenter prospective randomized trials evaluating fluorescence angiography in colorectal surgery. The Pillar III trial intended to evaluate approximately 550 patients undergoing open or minimally invasive proctectomy for rectosigmoid cancer, with a planned anastomosis of ≤10 cm from the anal verge. The primary end point was a reduction in leak rate and the secondary end points included technical feasibility and change in surgical plan. However, unfortunately, this trial was terminated after 330 patients.
We believe that there is enough evidence to support the claim that fluorescence angiography plays a significant role in reduction of anastomotic leaks in colorectal surgery, and we are confident that the results from both prospective randomized trials will reflect our opinion.
C01. Shogan BD, Carlisle EM, Alverdy JC, et al. Do we really know why colorectal anastomoses leak? J Gastrointest Surg. 2013;17(9):1698–1707.
C02. Al Asari S, Cho MS, Kim NK. (2015) Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center. Eur J Surg Oncol 41(2):175–185
C03. Chadi, S.A., et al., Emerging Trends in the Etiology, Prevention, and Treatment of Gastrointestinal Anastomotic Leakage. J Gastrointest Surg, 2016. 20(12): p. 2035-2051.
C04. Vallance, A., et al., A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis, 2017. 19(1): p. O1-O12.
The webinar will describe the basic principles of fluorescence guided surgery with special interest in the field of organ perfusion control using fluorescent angiography. An extensive review of the available literature will also be discussed.
Recently, in vivo fluorescence imaging using indocyanine green (ICG) has actively been applied to open and then laparoscopic HPB surgery, for intraoperative visualization of biological structures and assessment of blood perfusion. This webinar will discuss the methods and results.
Intraoperative fluorescence imaging will develop into an essential navigation tool enabling surgeons to identify the extent of cancer spread, anatomical variations, and a risk of postoperative complications in each individual case, enhancing accuracy and safety of HPB surgery.
Takeaki Ishizawa MD, PhD, FACS
Lector at Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, University of Tokyo Hospital, Tokyo, Japan
Surgery on lymph system has become an important long-term treatment of lymphedema. The performance of this demanding surgical procedure is increasing all over the world. In order to be able to assess the situation of the lymphedema and to decide on the lymph surgery an assessment of the lymphatics is necessary. The fluorescence angiography allows you to visualize the functionality, individual physiology, velocity of the lymphatics and thus severity of a lymphedema. Having the real-time picture of the patient’s lymphatics surgeon can decide on the best suitable surgical procedure. This presentation will show the use of fluorescence lymphangiography and different surgical procedures on lymphedema treatment.
WEBINAR: 5 November, 2018
The assessment of the flap perfusion in reconstruction surgery is mostly based on clinical evaluation. Unfortunately, surgeons still face some risk of complications if the flap tissue is not well perfused. Indocyanine Green (ICG) angiography allows the surgeon to define the boundaries of the perforator perfusion zones of a flap with high sensitivity, avoiding partial flap loss and fat necrosis. With the combination of preoperative Computed Tomography Angiography (CTA) and intraoperative ICG, we can define the post-dissection vascular re-balance, speed up the flap dissection and avoid post-operative flap complications. This lecture will provide you a clear understanding of the procedure and benefits of the fluorescence diagnostic method used in flap reconstruction surgery.
WEBINAR: 12 November, 2018
Frank Papay, MD
Esophagectomy for esophageal cancer is still associated with a high morbidity and mortality. Anastomotic leaks are a major source of morbidity after esophagectomy with gastric pull-up. In large part they occur as a consequence of poor blood perfusion in the gastric graft. Risk factors like nicotine, neoadjuvant radiotherapy, hypertension and diabetes are considered to increase anastomotic leakage rate. Ongoing challenge is to improve technical options for better patients’ outcome. Because of knowledge that quality of gastric tube perfusion is obviously related with anastomotic healing the use of fluorescence controlled construction of gastric tube makes this procedure safer for our patients.
This lecture gives an overview of this approach and current literature.
Sylke Schneider, MD
Senior Consultant Dept. visceral surgery
Klinikum Südstadt Rostock, Germany
Specialist for general, visceral and bariatric surgery
Indocyanine Green (ICG) is being utilized to identify both normal parathyroid glands during thyroidectomy and also to identify parathyroid adenomas during parathyroidectomy for primary or secondary hyperparathyroidism. The use of ICG allows for assessment of parathyroid perfusion. By using ICG, surgeons may be able to reduce the incidence of hypoparathyroidism following thyroidectomy and also may find it useful to identify parathyroid adenomas. For adrenal surgery, ICG allows identification of the blood supply and venous drainage of the tumor that at times can be challenging. This lecture will provide you a clear understanding of the use and benefits of the use if ICG in endocrine surgery.
Michael Bouvet, MD, FACS
Professor of Surgery
Director of Endocrine Surgery
Division of Surgical Oncology
Department of Surgery
University of California San Diego
Moores Cancer Center
Michele Diana, MD
Research Director of the Endo-Laparoscopic Procedures Unit at the IHU-Strasbourg, Institute of Image-Guided Surgery Senior Researcher and Faculty Member at the IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France