Navigation

Stage

Highlights

Fluorescence Imaging

KARL STORZ – Near infrared (NIR/ICG)

discover new facets of light!

The NIR/ICG system from KARL STORZ allows visualization beneath the tissue surface and detects the distribution of the fluorescent dye indocyanine green (ICG).

Special Features:

  • Can be used for white light and fluorescence imaging
  • Parallel fluorescence imaging and background illumination
  • Quick and easy switchover between white light and fluorescence mode via footswitch
  • Telescopes for endoscopic and open-surgical interventions
  • Optimal illumination and contrast enhancement
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

Assessing the perfusion of a colon section is quick and easy with the NIR/ICG system from KARL STORZ. The monitoring of the rapid influx of ICG in the tissue allows the easy identification of the ischemic areas. Doctors using the system feel assured of their decisions.

  • Direct intraoperative diagnosis decreases surgery time
  • Rapid perfusion assessment of the intended resection zone
  • Perfusion problems can be identified by ICG which can be utilized for resection
  • Visualization of structural landmarks below the tissue surface in real-time
Fluorescence cholangiography during a cholecystectomy
Fluorescence cholangiography during a cholecystectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Intravenously administered ICG naturally collects in the biliary system. The collected ICG can be fluorescently excited with the NIR/ICG system from KARL STORZ, resulting in rapid identification of the biliary system anatomy. Switching between white light and fluorescence modes is performed at the touch of a button and cholecystectomies can be performed easily in a laparoscopic or open-surgical approach.

  • Shortened operation time with ICG compared to intraoperative cholangiography
  • Biliary tree mapping with ICG guidance makes the rapid delineation of the cystic duct, common bile duct and Portal vein possible
  • Intraoperative detection of bile leakage
  • Open and minimally invasive interventions can be undertaken seamlessly as only the telescopes, and not the entire camera system, need to be exchanged
Laparoscopic transverse colectomy with fluorescence-guided lymphadenectomy
Laparoscopic transverse colectomy with fluorescence-guided lymphadenectomy – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy

Visualizing the lymphatic system can be very helpful in many areas. The NIR/ICG system from KARL STORZ enables visualization of ICG through the lymphatic system. Doctors using the system appreciate the visual control and guidance of this fluorescence technique.

  • NIR allows the intraoperative detection of sentinel lymph nodes and the lymphatic system network
  • Radiation-free fluorescence guidance technique is used to predict metastatic migration through the lymphatic system
  • Makes en-bloc resection of lymph nodes easier
  • High node detection rates compared to established methods of lymph node visualization
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.

Extracorporeal colon anastomosis with VITOM® II ICG – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)
Extracorporeal colon anastomosis with VITOM® II ICG – Source: Prof. Luigi Boni, University of Insubria, Varese, Italy (endoscopic image)

Many colorectal surgeries are performed openly. The VITOM® II ICG exoscope may be used with the KARL STORZ – Near Infrared (NIR/ICG) System to transfer the benefits of NIR/ICG imaging to open surgery. The imaging equipment is the same, only the telescope has to be changed.

Spectra A mode of the IMAGE1 S camera system is recommended to be used with the VITOM® II ICG for optimal fluorescence results. Easily handleable holding arms integrate the VITOM® II ICG exoscope perfectly in the surgeon’s working Environment.

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.

Photodynamic diagnostics (PDD)

Special features:

  •  Complete PDD system for diagnosis, treatment, and follow-up care
  • Outstanding image quality in the flexible and rigid system as well as in white light and
    PDD modes
  • Cost efficiency through compatible components and customer-oriented solutions
  •  User safety through the PDD-QAT

Features that are invisible under regular light can be visualized with blue light using specially modified endoscopes.

Photodynamic diagnostics (PDD) allows visually differentiating malignant changes from healthy tissue at an early stage. For this purpose, light of a special spectral range is guided into the body through a nearly loss-free optical fiber system.

The D-LIGHT C light source is a key element of the PDD unit. After instilling a tumor marker substance, malignant tissue can be differentiated from benign tissue in the fluorescence mode: cancerous areas in the bladder fluoresce red when exposed to the stimulation light from the D-LIGHT C system. This facilitates the detection of flat neoplastic lesions such as dysplasias and carcinoma in situ, which can be concealed by normal or unspecifically inflamed mucus membranes, as well as small papillary tumors. White light alone does not achieve such differentiation, and consequently such early findings may be overlooked.

KARL STORZ started selling the first system for photodynamic diagnostics as early as 1995. Systems consist of precisely harmonized components: the high performance light source D-LIGHT C, special telescopes, and a particularly light-sensitive endoscopy camera. PDD relies on suitable and approved marker substances.

Autofluorescence (AF)

Special Features:

  • Excellent image quality in both examination modes – thanks to modern CCD video chip technology and integrated auto-focus function
  • Optimal gliding movement of the distal tip that responds exactly to controls – thanks to the robust design of the insertion sheath using high-quality materials
  • Accurate and user-friendly work during an intervention – thanks to the ergonomic handle design and the particularly light overall weight
  • Rapid changeover between white light and autofluorescence modes – thanks to convenient activation of the function keys

Autofluorescence (AF) can differentiate even early malignant changes from benign tissue. The autofluorescence technique is based on the fact that some substances in the submucosa fluoresce when exposed to light of a certain wavelength. Pathological findings are visible as dark areas against an apple-green background (normal tissue).

Features that are invisible under regular light can be visualized with blue light using specially modified endoscopes. For this purpose, light of a special spectral range is guided into the body through a nearly loss-free optical fiber system. The system's major advantage is the fact that it does not require marker substances. One of its applications is the early diagnosis of bronchial cancer.

The D-LIGHT C/AF light source is a key element of the KARL STORZ AF unit. In the fluorescence mode, malignant and benign tissue can be differentiated.
AF is used in ENT, bronchoscopy, laparoscopy, and for gynecological indications.