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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

Fluorescence Imaging with the Modular IMAGE1 S Camera Platform from KARL STORZ

For imaging with the fluorescent dye indocyanine green (ICG)*, KARL STORZ offers 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.

  • 5 mm telescope available
  • Multidisciplinary applications, e.g., in general and visceral surgery, thoracic surgery, gynecology, urology, and reconstructive surgery
  • Xenon-based technology (no laser safety measures necessary)
  • Optimal illumination and contrast enhancement
  • All-in-one solution for laparoscopic and open surgery with VITOM® II ICG
  • Outstanding user-friendliness


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

Example of perfusion assessment in the colon – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy
Example of perfusion assessment in the colon – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Perfusion assessment plays an important role in various medical disciplines. 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, e.g. in colon3 or esophageal resections and gastric bypass4
  • Perfusion assessment in flap plasty
  • Visualization of liver segments


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

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

Fluorescence-assisted cholecystectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy
Fluorescence-assisted cholecystectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Due to hepatobiliary excretion, ICG naturally collects in the gallbladder and bile ducts. This allows the rapid and reliable identification of the gallbladder and bile duct anatomy. Thanks to enhanced visualization of the biliary anatomy, cholecystectomy can be performed more quickly and with greater assurance.

  • Allows a reliable differentiation between the cystic duct and common bile duct1
  • Intraoperative leaks displayed with ICG
  • Shortened surgical duration with ICG compared to standard cholangiography2


1Boni et al., NIR/ICG Fluorescence Imaging in Laparoscopic Surgery, Doctor-to-Doctor Manual ENDO-PRESS®,
(ISBN 978-3-89756-934-8)

2Dip 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 reliable identification of the lymphatic system presents a challenge in oncological interventions. The use of NIR/ICG imaging can provide intraoperative visualization of the entire lymphatic system downstream of the tumor in real time. Nuclear medicine imaging procedures can thus be avoided11.

  • Non-radioactive method for lymph node visualization
  • Detection rates compare favorably with established methods of lymph node visualization12
  • Multidisciplinary use, e.g., in gynecology, urology, and general surgery


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

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

12 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

Perfusion control for setting a colorectal anastomosis – Source: Matej Skrovina, M.D., Head of Department of Surgery, Novy Jicin Hospital, CZ
Perfusion control for setting a colorectal anastomosis – Source: Matej Skrovina, M.D., Head of Department of Surgery, Novy Jicin Hospital, CZ

Colorectal cancer is the third most common cancer in Germany5. In most cases, radical surgery is the only way for total treatment. Good circulation in the area around the anastomosis is an important factor in the healing process of colorectal anastomoses. Anastomosis insufficiency can thus be prevented.

  • The NIR/ICG system allows intraoperative perfusion assessment in real time, e.g., to delineate suitable resection zones
  • Boni et al.6 showed that perfusion assessment can reduce the rate of anastomotic leakage
     

5 Robert Koch Institute, Berlin, Germany

6 Boni et al., Indocyanine green-enhanced fluorescence to assess bowel perfusion during laparoscopic
colorectal resection, 2016

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

With KARL STORZ near-infrared (NIR/ICG) technology and the marker indocyanine green (ICG), the entire lymphatic system around the tumor can be visualized in real time without radiation exposure.

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 the surgical experience as follows: NIR/ICG technology allows performing less radical lymphadenectomy, and visual control simultaneously simplifies the en-bloc resection of lymph nodes.

*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. 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 field13.

A study on SLN mapping of endometrial carcinoma yielded the following results (99mTc vs. ICG):

 

  Radioaktiver Tracer 99mTc ICG

SLN detection rate

Bilateral SLN

Total SLN detection rate

Bilateral SLN

Imboden et al.14

 83 %  61 %  95.5 %  95.5 %


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

14 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

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 literature:

  • Urology15,16:
    • Prostate carcinoma
    • Penile carcinoma
  • General Surgery17,18:
    • Colorectal carcinoma
    • Pancreatic carcinoma
    • Gastric carcinoma

 

15 Jeschke et al., Visualisation of the lymph node pathway in real time by laparoscopic radioisotope- and fluorescence-guided sentinel lymph node dissection in prostate cancer staging, 2012

16 Hruby et al., Fluorescence Guided Targeted Pelvic Lymph Node Dissection for intermediate and high risk prostate cancer, 2015

17 Boni et al., Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery, 2014

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

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

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

  • Enables open surgical and fluorescence-assisted interventions in various disciplines such as, for example, the visualization of lymphatic vessels and nodes as well as perfusion during flap grafts
  • Possible to integrate the VITOM® II ICG into the surgeon’s operating field by means of a holding arm
  • For optimal fluorescence results, the SPECTRA A* mode in the IMAGE1 S camera unit can be activated to achieve contrast enhancement
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.7 The NIR/ICG system with the fluorescent dye ICG 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 surface8
  • Possible to diagnose small metastases with millimeter accuracy9
  • Easier to determine the extent of the resection10


7 Cancer in Germany 2011/2012 (10th Edition), Robert Koch Institute, Berlin, Germany

8 Within accuracy of 1 cm depending on the tissue composition

9 Tummers et al., First experience on laparoscopic near-infrared fluorescence imaging of hepatic uveal melanoma metastases using indocyanine green, 2014

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

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

The selective administration of ICG assists the identification of various liver segments during partial liver resection in both laparoscopic and open surgical procedures. Partial liver resection requires a sound knowledge of the existing course of the vessel and the boundaries of the individual segments while taking the diverse anatomical features of the blood vessels into consideration:

  • The tumor is localized pre- or 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 KARL STORZ NIR/ICG Technology 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.

Additional information on the specialty

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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

Fluorescence Imaging

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

Human Medicine

Fluorescence Imaging

Litvack ZN, Zada G, Laws ER Jr.

J Neurosurg. 2012 Feb 24.

Endoscopic ICG perfusion imaging for flap transplants: clinical results

Human Medicine

Fluorescence Imaging

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

Human Medicine

Fluorescence Imaging

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

Human Medicine

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

Fluorescence Imaging

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