Fluorescence-guided lymphadenectomy in gastric cancer surgery: a novel intraoperative indocyanine green injection.
Fluorescence-guided lymphadenectomy using indocyanine green (ICG) improves intraoperative visualization of gastric lymphatic drainage during gastrectomy. Most reported techniques rely on preoperative endoscopic injection, and standardized intraoperative protocols are limited.
To evaluate the feasibility, safety, and lymph node retrieval of intraoperative subserosal ICG injection for fluorescence-guided D2 lymphadenectomy during laparoscopic gastrectomy.
A prospective descriptive pilot study was conducted at two institutions. Consecutive patients with gastric adenocarcinoma undergoing laparoscopic total or subtotal gastrectomy with curative intent and D2 lymphadenectomy were included. ICG was injected intraoperatively into the anterior gastric wall (two injections of 1.25 mg) after diagnostic exploration. Outcomes included feasibility, safety, fluorescence distribution across D2 stations, and total lymph node retrieval.
Twenty patients were included. The protocol was successfully implemented in all cases without technical difficulties or ICG-related adverse events. Complete D2 lymphadenectomy was achieved in 100% of patients. The median number of retrieved lymph nodes was 39 (range 29-73), with =30 nodes in 95% of cases. Fluorescent nodes were consistently identified in stations 3, 4, 6, and 7, with variable distribution in stations 5, 9, 8a, 11, 1, and 2, and absent in station 12a.
Intraoperative subserosal ICG injection is a feasible, safe, and reproducible technique that enables consistent visualization of major gastric lymphatic basins without requiring preoperative endoscopic injection.
Surgical resection with D2 lymphadenectomy continues to be the cornerstone of curative treatment of gastric cancer. However, the complex and variable vascular and lymphatic anatomy of the stomach makes lymph node dissection a technically demanding component of gastrectomy. Achieving an adequate lymphadenectomy is crucial not only for reducing residual disease, but also for ensuring accurate pathological staging, which directly influences prognosis and the indication for adjuvant therapy. Fluorescence-guided surgery with indocyanine green (ICG) has gained attention as a tool to improve intraoperative visualization of lymphatic drainage pathways. Because it allows real-time visualization of lymphatic flow and nodal stations under near-infrared imaging, this approach may improve the precision, reproducibility, and safety of lymphadenectomy.
This study describes a novel intraoperative ICG injection protocol for fluorescence-guided D2 lymphadenectomy during laparoscopic gastrectomy, and demonstrates its feasibility, safety, and reproducibility in a consecutive cohort. The protocol enabled consistent real-time visualization of major gastric lymphatic basins, and allowed systematic assessment of fluorescence across all D2 lymph node stations without requiring preoperative endoscopic injection. These preliminary findings support the technical applicability of this approach, and should be further evaluated in larger series aimed at validating its clinical utility and exploring its potential role within standardized fluorescence-guided lymphadenectomy workflows.
To evaluate the feasibility, safety, and lymph node retrieval of intraoperative subserosal ICG injection for fluorescence-guided D2 lymphadenectomy during laparoscopic gastrectomy.
A prospective descriptive pilot study was conducted at two institutions. Consecutive patients with gastric adenocarcinoma undergoing laparoscopic total or subtotal gastrectomy with curative intent and D2 lymphadenectomy were included. ICG was injected intraoperatively into the anterior gastric wall (two injections of 1.25 mg) after diagnostic exploration. Outcomes included feasibility, safety, fluorescence distribution across D2 stations, and total lymph node retrieval.
Twenty patients were included. The protocol was successfully implemented in all cases without technical difficulties or ICG-related adverse events. Complete D2 lymphadenectomy was achieved in 100% of patients. The median number of retrieved lymph nodes was 39 (range 29-73), with =30 nodes in 95% of cases. Fluorescent nodes were consistently identified in stations 3, 4, 6, and 7, with variable distribution in stations 5, 9, 8a, 11, 1, and 2, and absent in station 12a.
Intraoperative subserosal ICG injection is a feasible, safe, and reproducible technique that enables consistent visualization of major gastric lymphatic basins without requiring preoperative endoscopic injection.
Surgical resection with D2 lymphadenectomy continues to be the cornerstone of curative treatment of gastric cancer. However, the complex and variable vascular and lymphatic anatomy of the stomach makes lymph node dissection a technically demanding component of gastrectomy. Achieving an adequate lymphadenectomy is crucial not only for reducing residual disease, but also for ensuring accurate pathological staging, which directly influences prognosis and the indication for adjuvant therapy. Fluorescence-guided surgery with indocyanine green (ICG) has gained attention as a tool to improve intraoperative visualization of lymphatic drainage pathways. Because it allows real-time visualization of lymphatic flow and nodal stations under near-infrared imaging, this approach may improve the precision, reproducibility, and safety of lymphadenectomy.
This study describes a novel intraoperative ICG injection protocol for fluorescence-guided D2 lymphadenectomy during laparoscopic gastrectomy, and demonstrates its feasibility, safety, and reproducibility in a consecutive cohort. The protocol enabled consistent real-time visualization of major gastric lymphatic basins, and allowed systematic assessment of fluorescence across all D2 lymph node stations without requiring preoperative endoscopic injection. These preliminary findings support the technical applicability of this approach, and should be further evaluated in larger series aimed at validating its clinical utility and exploring its potential role within standardized fluorescence-guided lymphadenectomy workflows.
Authors
Lanzarini Lanzarini, Cruz Cruz, Sallaberry Sallaberry, Gaete Gaete, Fernández Fernández, Musleh Musleh
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