ICG-assisted D3 lymphadenectomy in right colectomy for cancer

Background: The presence of regional lymph node (LN) metastasis is a strong negative prognostic factor in colorectal cancer (CLRC). Recent advances in surgical management of CLRC, such as complete mesocolic excision (CME) with central vascular ligation (CVL), are focused on quality of surgical specimen, including an increase of LN count, in order to obtain a better survival than standard surgery. The aim of the study is to verify if intraoperative real-time visualization of the lymph flow, using indocyanine green fluorescence imaging (ICG-FI), improves lymphadenectomy during laparoscopic right hemicolectomy for cancer, performed according to CME/CVL criteria. Methods: This is a monocentric, non-randomized prospective pilot study. From January 2019 to October 2019 we analyzed data form 20 patients with right colon cancer who underwent laparoscopic resection with D3 lymphadenectomy fluorescence guided by means of intraoperative injection of ICG. Results: A total of 20 patients undergoing laparoscopic right colectomy were enrolled: the mean operative time were 162 minutes. Median length of the anatomical preparation was 30 cm, the mean LN harvested was 30.65, the incidence of nodes metastasis was 55%. Nine patients underwent a change of therapeutic strategy based on intraoperative ICG-FI [8 for positive ICG-FI in superior mesenteric artery's (SMA's) nodes and 1 in the LNs of the middle colic artery (MCA)]. Conclusions: ICG-intraoperative lymphography gives additional intraoperative information about lymphatic flow during laparoscopic right colectomy for cancer and may lead to change, and sometimes extend, lymphadenectomy. Larger further randomized prospective trials are needed to validate this new technique.