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Fluorescence Imaging

Fluorescence techniques in minimally invasive surgery visualize features that are invisible under conventional white light. Autofluorescence (AF) uses the endogenous fluorescence of the mucosa to differentiate malignant tumors from healthy tissue at an early stage. Photodynamic diagnosis (PDD) detects the pathological accumulation of fluorescent porphyrin products in bladder tumors and allows rigorous treatment of these malignant changes. Use of near-infrared (NIR) imaging expands the spectrum of diagnostic options and enables the perfusion evaluation of organs and tissues and the visualization of the bile duct or visually supports the diagnosis of lymph nodes. Indocyanine green (ICG) is used in this case. At the heart of these imaging systems is the D-LIGHT light source as well as specially adapted telescopes and our HD camera systems.

Fluorescence-guided imaging techniques, particularly when applied with the new IMAGE1 S camera system, have shown to be valuable auxiliary modalities of visualization that can be used effectively in the surgeon’s decision-making on a regular basis.

Highlights

NIR/ICG fluorescence imaging with the KARL STORZ modular system solution

Using the fluorescent dye indocyanine green (ICG)* and light in the near infrared (NIR) range, KARL STORZ offers the NIR/ICG system for brilliant, laser-free FULL HD imaging of the vascular system, biliary tract, and lymphatic system. The NIR/ICG system is based on the IMAGE1 S camera platform.

  • NEW: 5 mm telescope now available
  • Multidisciplinary applications, for instance in general and visceral surgery, thoracic surgery, gynecology, urology, and reconstructive surgery
  • Xenon-based technology (no laser protection required)
  • Optimal illumination and contrast enhancement
  • All-in-one solution for laparoscopic and open surgery (VITOM® II ICG)
  • Outstanding user friendliness
     

*Please verify that the fluorescent dye indocyanine green is approved for the respective indication in your country.

Blood perfusion assessment of colon section in a colorectal cancer patient
Blood perfusion assessment of colon section in a colorectal cancer patient – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Perfusion assessment plays an important role in various medical specialties. Ischemic areas can be easily identified by using the NIR/ICG system and administering ICG. This allows intraoperative action to be taken and reduces the duration of surgery.

  • Rapid perfusion assessment of a planned resection zone as well as the subsequent anastomosis, including colonic anastomoses1, esophageal anastomoses, and gastric bypass anastomoses2
  • Perfusion assessment in flap plasty
  • Visualization of liver segments


1 Koh et al., Fluorescent Angiography Used to Evaluate the Perfusion Status of Anastomosis in Laparoscopic Anterior Resection, 2016

2 Boni et al., Clinical Applications of Indocyanine Green (ICG) Enhanced Fluorescence in Laparoscopic Surgery, 2015

Fluorescence cholangiography during a cholecystectomy
Fluorescence cholangiography during a cholecystectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Following intravenous administration, ICG naturally collects in the gallbladder and bile ducts. This allows the rapid and reliable identification of gallbladder and bile duct anatomy. Thanks to intuitive switching between white light and fluorescence imaging, cholecystectomy can be performed rapidly and more safely.

  • Allows the reliable differentiation between the cystic duct and common bile duct3
  • Intraoperative leaks displayed with ICG
  • Shortened surgical duration with ICG compared to standard cholangiography4


3 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, NIR/ICG Fluorescence Imaging in Laparoscopic Surgery (ISBN 978-3-89756-934-8)

4 Dip et al., Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy, 2014

*SPECTRA A: Not for sale in the U.S.

Laparoscopic transverse colectomy with fluorescence-guided lymphadenectomy
Laparoscopic transverse colectomy with fluorescence-guided lymphadenectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

The visualization of the lymphatic system is very helpful in many medical specialties. With NIR/ICG imaging, the entire lymphatic system5 around the tumor can be displayed in real time without use of radioactivity6.

  • Non-radioactive method for lymph node visualization
  • Detection rates compare favorably with established methods of lymph node visualization7
  • Multidisciplinary use, for instance in gynecology, urology, and general surgery


5 (S)LN by means of the intradermal administration of ICG is already approved in Italy (breast cancer), Japan and Russia. Please inform yourself in advance about the potential off-label use of ICG at your hospital and in your country.

6 Papadia et al., Doctor-to-Doctor Manual ENDO-PRESS®, ICG-Enhanced Fluorescence-Guided SLN Mapping in Gynecological Malignancies (ISBN 978-3-89756-932-4)

7 Imboden et al., A Comparison of Radiocolloid and Indocyanine Green Fluorescence Imaging, Sentinel Lymph Node Mapping in Patients with Cervical Cancer Undergoing Laparoscopic Surgery, 2015

Endoscopic colon anastomosis – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)
Endoscopic colon anastomosis – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)

The KARL STORZ – Near Infrared (NIR/ICG) System offers the possibility to assess if the perfusion of the colon is satisfactory. Laparoscopically, surgeons are naturally unable to control the anastomosis with palpation, but can control it visually, therefore NIR/ICG fluorescence angiography provides a real-time intraoperative solution.
NIR/ICG fluorescence angiography is quick and easy. To confirm blood supply is sufficient, the surgeon identifies the borders of the healthy bowel segment before setting the staple-line and immediately after completing the anastomosis. Well perfused tissue can be easily distinguished from ischemic areas by illumination of ICG after intravenous injection. Thereby, the surgeon can confirm the bowel resection borders are well perfused and if not can intervene immediately to re-set the anastomosis.

With more than 694,000 deaths worldwide in 2012 according to the WHO (World Health Organization), colorectal cancer is the third most common type of cancer. In most cases, radical surgery is the only way for total treatment.
Successful colorectal anastomosis is an important factor in the healing process of radical surgery. The perfusion of the anastomosed bowel segments is critical. The mean anastomotic leakage (AL) rate for colic and rectal anastomosis was 7.2%, whereas AL for rectal anastomosis alone was 8.8%1 resulting in a 6-22% mortality and 56% morbidity rate opposed to patients without AL after colorectal resection2.
KARL STORZ - Near Infrared (NIR/ICG) fluorescence angiography enables delineation of ischemic areas. According to a recent study the anastomotic leakage rate was reduced to 0% by using NIR/ICG imaging for the assessment of the perfusion during surgery3.

1. Pommergaard HC, et al. Colorectal Dis. 2014.
2. Daams F, et al. World J Gastroenterol. 2013.
3. Boni L, et al. Surg. Endos. 2015.

Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)

The KARL STORZ Near Infrared (NIR/ICG) system and the marker indocyanine green (ICG) enables non-radioactive visualization of the entire lymph system surrounding a tumor in real time.

The system offers the following advantages:

  • Non-radioactive lymph node detection method
  • Multidisciplinary use
  • Xenon-based technology (no laser safety measures necessary)
  • Intuitive switchover between the standard white light and the fluorescence mode via footswitch
  • Physicians describe their surgical experience with the system as follows:
    The NIR/ICG system allows the reduction of radical lymphadenectomy and, at the same time, visual control makes the en-bloc resection of lymph nodes easier.

*The intradermal administration of indocyanine green for (S)LN has already been approved in Italy (breast cancer), Japan and Russia. Please inform yourself in advance about the potential for the off-label use of ICG in your hospital / country.

Source: Prof. Cadière, Saint-Pierre University, Brussels, Belgium (endoscopic image)

In gynecology, the degree of tumor involvement in the sentinel lymph node (SLN) is of great importance as it provides medical information about the tumor stage and is thus one of the main prognostic factors. In breast cancer surgery, SLN detection with the radioactive tracer 99mTc is the gold standard. In other areas of gynecological tumor surgery, its benefits in comparison to elective lymph node dissection is the subject of discussion. As a new, non-radioactive imaging technique, NIR imaging with ICG can provide a useful contribution to this field.1 SLN mapping of endometrial carcinoma yielded the following results (radioactive tracer 99mTc vs. ICG):

 

  Radioaktiver Tracer 99mTc ICG

Total SLN
detection rate

Bilateral SLN

Total SLN detection rate

Bilateral SLN
Study 12  83 %  61 %  95,5 %  95,5 %

1Papadia et al., Silver Books, NIR/ICG-Enhanced Fluorescence-Guided Imaging of Malignant Tumors in Gynecology (ISBN 978-3-89756-931-7)

2 Imboden et al., Surg. Oncol. 2015

Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)

Fluorescence-guided visualization of the lymphatic system with the NIR/ICG system from KARL STORZ is now used in many other disciplines. The following examples have already been described in the literature:

Urology 1,2:

  • Prostate carcinoma
  • Penile carcinoma

General Surgery 3,4:

  • Colorectal carcinoma
  • Pancreatic carcinoma
  • Gastric carcinoma
     

1 Jeschke et al. 2012
2 Hruby et al. 2015
3 Boni et al. 2014
4 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, ICG-enhanced Fluorescence-guided Laparoscopic Surgery (ISBN 978-3-89756-934-8)

Source: Dr. García Valdecasas, Hospital Clínic de Barcelona, Spain

The VITOM® II ICG from KARL STORZ also offers an optimal solution for visualizing the lymph system in open surgery. VITOM® II ICG can be used with the NIR/ICG system.

  • Also allows fluorescence-supported lymph node detection in open surgery in various disciplines such as, for example, gynecology in the case of breast cancer
  • Possibility for the integration of an exoscope by means of a holding arm in the surgeon’s space
  • For optimal results, the SPECTRA A* visualization mode can also be activated to achieve contrast enhancement

* SPECTRA A: Not for sale in the U.S.

Source: Niclas Kvarnström, M.D., Sahlgrenska University Hospital, Göteborg, Sweden (application image)
Source: Niclas Kvarnström, M.D., Sahlgrenska University Hospital, Göteborg, Sweden (application image)

Illumination with near infrared light using indocyanine green (ICG) enables enhanced visualization of anatomical structures such as the biliary ducts, the lymphatic system and blood vessels. Use of the IMAGE1 S NIR system proves to be a versatile application in liver surgery. It allows the diagnosis of potential liver metastases, primary liver tumors or bile leakage and makes it possible to perform fluorescence-assisted liver segmentectomy.

The system offers the following advantages:

  • Multidisciplinary use in both endoscopy and open surgery
  • Laparoscopes with a diameter of 10 mm and now available with a diameter of 5 mm
  • Xenon-based technology (no laser safety measures necessary)
  • Intuitive switchover between standard white light and fluorescence mode via footswitch
Source: Takeaki Ishizawa, M.D., Tokyo University, Japan (application image)
Source: Takeaki Ishizawa, M.D., Tokyo University, Japan (application image)

Primary liver cancer is the sixth most common cancer worldwide. Liver metastases are even 20 times more common than primary liver tumors.1 The NIR/ICG system offers the following advantages for liver surgery:

  • ICG in conjunction with near infrared light allows the intraoperative visualization of metastases and carcinoma of the liver above or below the tissue surface2
  • Possible to diagnose small metastases with millimeter accuracy3
  • Easier to determine the extent of resection4

1 Krebsraten in Deutschland 2011/2012 (10.), Robert-Koch-Institut, Berlin
2 Within accuracy of 1 mm depending on the tissue composition
3 Tummers et al., First experience on laparoscopic near-infrared fluorescence imaging of hepatic uveal melanoma metastases using indocyanine green, 2014
4 Boni et al., Doctor-to-Doctor Manual ENDO-PRESS®, NIR/ICG Fluorescence Imaging in Laparoscopic Surgery (ISBN 978-3-89756-934-8)

Source: Niclas Kvarnström, M.D, Sahlgrenska University Hospital, Göteborg, Sweden
Source: Niclas Kvarnström, M.D, Sahlgrenska University Hospital, Göteborg, Sweden

A further possible application in liver surgery is the selective administration of ICG into the supply vessel in order to aid laparoscopic and open liver segmentectomy. Partial liver resection requires a sound knowledge of the existing course of the vessel and the boundaries of the individual segments as well as the diverse anatomical features of the blood vessels:

  • The tumor is localized intraoperatively aided by CT, MRI and ultrasound techniques
  • ICG is injected into the supply vessel of the segment
  • Fluorescence allows easy differentiation of the affected segment from the adjacent non-fluorescing segments

ICG fluorescence can also help to detect bile leakage following liver segmentectomy or liver transplantation procedures.

Source: Takeaki Ishizawa, M.D., Tokyo University, Japan
Source: Takeaki Ishizawa, M.D., Tokyo University, Japan

The VITOM® II ICG system from KARL STORZ offers an optimal solution for open liver surgery. VITOM® II ICG can easily be used with the IMAGE1 S NIR system in laparoscopy.

  • Enables both open surgical and fluorescence-assisted diagnosis of liver metastases and liver carcinoma as well as the visualization of liver segments and bile leakage
  • Possible to integrate VITOM® into the surgeon’s operating field by means of a holding arm
  • For optimal fluorescence results, the SPECTRA A visualization mode can also be activated. This results in a color shift in the image

The NIR/ICG System from KARL STORZ as a Modular System Solution for Diverse Applications

  • Visualization of the bile duct anatomy
  • Visualization of perfusion
    • Intraoperative perfusion assessment of colorectal anastomoses
    • Identification of ischemic area and vascular structures
  • Application in liver surgery
    • Visualization of liver segments
    • Diagnosis of liver metastases and carcinoma
  • Visualization of the lymph system
    • Identification of lymphatic vessels and lymph nodes
    • Lymphatic leakage

Stop Guessing. Start Knowing.

PDD – flexibility in visualization with IMAGE1 S

With Photodynamic Diagnosis (PDD) in FULL HD quality, another component has been added to the IMAGE1 S camera platform. The most outstanding feature of the HX FI camera heads is their versatile application possibilities. In addition to the PDD OPAL1™ technology, the S-Technologies CHROMA, SPECTRA A* and SPECTRA B* can also be displayed in white light.

  • Versatile camera heads with PDD fluorescence imaging and S-Technologies
  • Brilliant, razor-sharp FULL HD imaging
  • Impressive lightweight and ergonomic design
  • Both standard and pendulum camera heads available
  • Part of the IMAGE1 S camera platform – compatible with IMAGE1 S X-LINK
  • Easy-to-use PDD functionality via IMAGE1 S


* not for sale in the U.S.

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Fiber Optic Light Cable, Fluid Light Cable Models 495 xx

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Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery

Human Medicine

Fluorescence Imaging

Boni L, David G, Mangano A, Dionigi G, Rausei S, Spampatti S, Cassinotti E, Fingerhut A

Surgical Endoscopy. 2014 Oct 11

A Comparison of Radiocolloid and Indocyanine GreenFluorescence Imaging, Sentinel Lymph Node Mapping in Patients with Cervical Cancer

Human Medicine

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Imboden S, Papadia A, Nauwerk M, McKinnon B, Kollmann Z, Mohr S, Lanz S, Mueller MD

Annals of Surgical Oncology. 2015 Jun 30.

Indocyanine green fluorescence endoscopy for visual differentiation of pituitary tumor from surrounding structures

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Litvack ZN, Zada G, Laws ER Jr.

J Neurosurg. 2012 Feb 24.

Endoscopic ICG perfusion imaging for flap transplants: clinical results

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Christian Betz

Head Neck Oncol. 2010; 2(Suppl 1): O15. Published online 2010 October 29. doi: 10.1186/1758-3284-2-S1-O15

Semi-quantitative Fluorescence Endoscopy with use of ICG

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Hilmar Schachenmayr, Sven Zhorzel, Herbert Stepp, Ulrich Harréus und Christian Stephan Betz

World Congress on Medical Physics and Biomedical Engineering, September 7 - 12, 2009, Munich, Germany IFMBE Proceedings, 2009, Volume 25/6, 118-119, DOI: 10.1007/978-3-642-03906-5_32

Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: preliminary results

Human Medicine

Fluorescence Imaging

Betz CS, Zhorzel S, Schachenmayr H, Stepp H, Havel M, Siedek V, Leunig A, Matthias C, Hopper C, Harreus U.

J Plast Reconstr Aesthet Surg. 2009 Dec;62(12):1602-8. Epub 2008 Nov 25

Lymph node pathway visualization in real time by laparoscopic radioisotope- and fluorescence- guided sentinel lymph node dissection in prostate cancer staging

Human Medicine

Fluorescence Imaging

Jeschke, S., Lusuardi, L., Myatt, A., Hruby, S., Janetschek, G.

27th Annual Congress of the European Association of Urology Paris, February 27, 2012

IntraoperativeLaparoscopicFluorescenceGuidance to the Sentinel Lymph Node in Prostate Cancer Patients: Clinical Proof of Concept of an Integrated Functional Imaging Approach Using a Multimodal Tracer

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Fluorescence Imaging

Henk G. van der Poela, Tessa Buckleb, Oscar R. Brouwerb, Renato A. Valdés Olmosb, Fijs W.B. van Leeuwenb

European Urology Volume 60, Issue 4, October 2011, Pages 826–833

Die laparoskopische Fluoreszenzangiographie mit Indocyaningrün zur intraoperativen Beurteilung der Perfusion bei kolorektalen Anastomosen

Human Medicine

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T. Carus und H. Lienhard

Deutsche Gesellschaft für Chirurgie, 2009, Volume 38, Chirurgisches Forum und DGAV Forum 2009 , XXIII, 331-333, DOI: 10.1007/978-3-642-00625-8_120