Sentinel node procedure of the sigmoid using indocyanine green: feasibility study in a goat model.
BACKGROUND
The sentinel lymph node (SLN) procedure alter the strategy for the treatment of patients with colon cancer. New techniques emerge that may provide the surgeon with a tool for accurate intraoperative detection of the SLNs.


METHODS
An SLN procedure of the sigmoid was used in six goats. During laparoscopy, the near-infrared dye indocyanine green (ICG) was injected into the subserosa of the sigmoid via a percutaneously inserted needle during four experiments and in the submucosa during colonoscopy in two experiments. After injection, the near-infrared features of a newly developed laparoscope were used to detect the lymph vessels and SLNs. At the end of the procedure, 2 h after injection, all the goats were killed, and autopsy was performed. During postmortem laparotomy, the sigmoid was removed and used for confirmation of ICG node uptake.


RESULTS
In all the procedures, the lymph vessels were easily detected by their bright fluorescent emission. In the first two experiments, no lymph nodes were detected. In the subsequent four experiments, human serum albumin was added to the ICG solution before injection to enable better lymph node entrapment. In all four experiments, at least one bright fluorescent lymph node was found after the lymph vessels had been tracked by their fluorescent guidance. The mean time between injection and SLN identification was 10 min. In two cases, the SLNs were located up to 5 mm into the fat tissue of the mesentery and were not seen by regular vision of the laparoscope. By switching on the near-infrared features of the scope, a clear bright dot became visible, which increased in intensity after opening of the mesentery.


CONCLUSIONS
The SLN procedure for the sigmoid using near-infrared laparoscopy in the goat is a very promising technique. Achievements described in this report justify a clinical trial on the feasibility of ICG-guided SLN detection in humans.
van der Pas
M H G M
MH
Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands. m.pas@vumc.nl
van Dongen
G A M S
GA
Cailler
F
F
Pèlegrin
A
A
Meijerink
W J H J
WJ
D000818:Animals; D012809:Colon, Sigmoid; D003110:Colonic Neoplasms / Q000473:pathology; D003113:Colonoscopy; D004396:Coloring Agents / Q000493:pharmacokinetics; D005240:Feasibility Studies; D005260:Female; D006041:Goats; D007208:Indocyanine Green / Q000493:pharmacokinetics; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D008198:Lymph Nodes / Q000378:metabolism / Q000473:pathology*; D008207:Lymphatic Metastasis / Q000473:pathology*; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*
D004396:Coloring Agents; D007208:Indocyanine Green