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      Use real-time near-infrared fluorescence during Heller’s cardiomyotomy for achalasia cardia

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          Abstract

          Laparoscopic Heller’s cardiomyotomy is the surgical procedure of choice in the management of oesophageal achalasia. It is critical to confirm the completeness of the myotomy and mucosal integrity at the conclusion of the procedure. This is conventionally achieved by intraoperative endoscopy and dynamic air leak test. Other modalities that can be used to confirm the myotomy and the integrity of the mucosa at the myotomy site are oesophageal manometry and a methylene blue dye study, respectively. Indocyanine green (ICG) has been in clinical use for more than six decades. The real-time integration of ICG fluorescence with laparoscopy is a relatively new breakthrough. Here, we present a novel method of using real-time near-infrared ICG fluorescence for confirming the completeness of the myotomy and mucosal integrity at the myotomy site post laparoscopic Heller’s myotomy. This is the first report on the use of ICG in laparoscopic Heller’s cardiomyotomy that we are aware of.

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          Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial

          The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.
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            Randomized, double-blind comparison of indocyanine green with or without albumin premixing for near-infrared fluorescence imaging of sentinel lymph nodes in breast cancer patients.

            Near-infrared (NIR) fluorescence imaging has the potential to improve sentinel lymph node (SLN) mapping in breast cancer. Indocyanine green (ICG) is currently the only clinically available fluorophore that can be used for SLN mapping. Preclinically, ICG adsorbed to human serum albumin (ICG:HSA) improves its performance as a lymphatic tracer in some anatomical sites. The benefit of ICG:HSA for SLN mapping of breast cancer has not yet been assessed in a clinical trial. We performed a double-blind, randomized study to determine if ICG:HSA has advantages over ICG alone. The primary endpoint was the fluorescence brightness, defined as the signal-to-background ratio (SBR), of identified SLNs. Clinical trial subjects were 18 consecutive breast cancer patients scheduled to undergo SLN biopsy. All patients received standard of care using (99m)Technetium-nanocolloid and patent blue. Patients were randomly assigned to receive 1.6 ml of 500 μM ICG:HSA or ICG that was injected periareolarly directly after patent blue. The Mini-Fluorescence-Assisted Resection and Exploration (Mini-FLARE) imaging system was used for NIR fluorescence detection and quantitation. SLN mapping was successful in all patients. Patient, tumor, and treatment characteristics were equally distributed over the treatment groups. No significant difference was found in SBR between the ICG:HSA group and the ICG alone group (8.4 vs. 11.3, respectively, P = 0.18). In both groups, the average number of detected SLNs was 1.4 ± 0.5 SLNs per patient (P = 0.74). This study shows that there is no direct benefit of premixing ICG with HSA prior to injection for SLN mapping in breast cancer patients, thereby reducing the cost and complexity of the procedure. With these optimized parameters that eliminate the necessity of HSA, larger trials can now be performed to determine patient benefit.
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              The Use of Fluorescence Angiography During Laparoscopic Sleeve Gastrectomy

              Background and Objectives: A new technology involving indocyanine green (ICG) fluorescence angiography has been introduced to assess tissue perfusion and perform vascular mapping during laparoscopic surgery. The purpose of this study was to describe the use of this technology to identify the variable blood supply patterns to the stomach and gastroesophageal (GE) junction during laparoscopic sleeve gastrectomy (LSG), which may help in preserving the blood supply and preventing ischemia-related leaks. Methods: Eighty-six patients underwent LSG and were examined intraoperatively with fluorescence angiography at an academic bariatric center from January 2016 to September 2017. Before the construction of the SG, 1 mL ICG was injected intravenously, and near infrared fluorescence imaging technology was used to identify the blood supply of the stomach. Afterward, the LSG was created with attention to preserving the identified blood supply to the GE junction and gastric tube. Finally, 3 mL ICG was injected to ensure that all the pertinent blood vessels were preserved. Results: Eighty-six patients successfully underwent the laparoscopic procedure with no complications. The following patterns of blood supply to the GE junction were found: (1) a right-side–dominant pattern (20%), arising from the left gastric artery; (2) a right-side–accessory pattern (36%), running in the gastrohepatic ligament and comprising either an accessory hepatic artery or an accessory gastric artery; and (3) a left-side accessory pattern arising from tributaries from the left inferior phrenic artery significantly contributing to the right-side blood supply. In addition, in 10% of the cases both right and left accessory patterns were present simultaneously. Conclusion: ICG fluorescence angiography allows determination of the major blood supply to the proximal stomach before any dissection during sleeve gastrectomy, so that an effort can be made to avoid unnecessary injury to these vessels during the procedure.
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                Author and article information

                Journal
                J Minim Access Surg
                J Minim Access Surg
                JMAS
                J Min Access Surg
                Journal of Minimal Access Surgery
                Wolters Kluwer - Medknow (India )
                0972-9941
                1998-3921
                Jul-Sep 2023
                14 March 2023
                : 19
                : 3
                : 447-449
                Affiliations
                [1]Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospital, Bengaluru, Karnataka, India
                Author notes
                Address for correspondence: Dr. Srikanth Gadiyaram, Department of Surgical Gastroenterology and Minimally Invasive Surgery, Sahasra Hospital, New No 30, 39 th Cross, Jayanagar 8 th Block, Bengaluru - 560 082, Karnataka, India. E-mail: srikanthgastro@ 123456gmail.com
                Article
                JMAS-19-447
                10.4103/jmas.jmas_194_22
                10449047
                37282425
                2cb2cec7-c719-4d10-8e90-4694056c7c3f
                Copyright: © 2023 Journal of Minimal Access Surgery

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 09 July 2022
                : 25 October 2022
                : 01 December 2022
                Categories
                How I Do It Differently

                Surgery
                achalasia cardia,indocyanine green,intraluminal fluorescence,laparoscopic heller’s cardiomyotomy,mucosal perforation,near-infrared fluorescence

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