title: Review of fluorescence guided surgery systems: identification of key performance capabilities beyond indocyanine green imaging.
abstract: There is growing interest in using fluorescence imaging instruments to guide surgery, and the leading options for open-field imaging are reviewed here. While the clinical fluorescence-guided surgery (FGS) field has been focused predominantly on indocyanine green (ICG) imaging, there is accelerated development of more specific molecular tracers. These agents should help advance new indications for which FGS presents a paradigm shift in how molecular information is provided for resection decisions. There has been a steady growth in commercially marketed FGS systems, each with their own differentiated performance characteristics and specifications. A set of desirable criteria is presented to guide the evaluation of instruments, including: (i) real-time overlay of white-light and fluorescence images, (ii) operation within ambient room lighting, (iii) nanomolar-level sensitivity, (iv) quantitative capabilities, (v) simultaneous multiple fluorophore imaging, and (vi) ergonomic utility for open surgery. In this review, United States Food and Drug Administration 510(k) cleared commercial systems and some leading premarket FGS research systems were evaluated to illustrate the continual increase in this performance feature base. Generally, the systems designed for ICG-only imaging have sufficient sensitivity to ICG, but a fraction of the other desired features listed above, with both lower sensitivity and dynamic range. In comparison, the emerging research systems targeted for use with molecular agents have unique capabilities that will be essential for successful clinical imaging studies with low-concentration agents or where superior rejection of ambient light is needed. There is no perfect imaging system, but the feature differences among them are important differentiators in their utility, as outlined in the data and tables here.
authors.affiliation: Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire 03755, United States.
authors.forename: Alisha V
authors.initials: AV
authors.lastname: DSouza
authors.affiliation: Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire 03755, United StatesbFujian Normal University, MOE Key Laboratory of OptoElectronic Science and Technology for Medicine, Fujian Provincial Key Laboratory for Photonics Technology, Fuj.
authors.forename: Huiyun
authors.initials: H
authors.lastname: Lin
authors.affiliation: Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire 03756, United States.
authors.forename: Eric R
authors.initials: ER
authors.lastname: Henderson
authors.affiliation: Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire 03755, United StatesdDartmouth College, Geisel School of Medicine, Department of Surgery, Hanover, New Hampshire 03755, United States.
authors.forename: Kimberley S
authors.initials: KS
authors.lastname: Samkoe
authors.affiliation: Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire 03755, United StatesdDartmouth College, Geisel School of Medicine, Department of Surgery, Hanover, New Hampshire 03755, United States.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Pogue
mesh_terms: D005456:Fluorescent Dyes / Q000737:chemistry / Q000378:metabolism*; D006801:Humans; D007208:Indocyanine Green / Q000378:metabolism; D008029:Lighting; D061848:Optical Imaging; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods*
chemical_list: D005456:Fluorescent Dyes; D007208:Indocyanine Green