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Original Investigation
February 26, 2020

Safety and Efficacy of Indocyanine Green Tracer-Guided Lymph Node Dissection During Laparoscopic Radical Gastrectomy in Patients With Gastric Cancer: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Gastric Surgery, Fujian Medical University Union Hospital, Fuzhou, China
  • 2Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, China
  • 3Key Laboratory of Ministry of Education of Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
  • 4Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
JAMA Surg. 2020;155(4):300-311. doi:10.1001/jamasurg.2019.6033
Key Points

Question  Can indocyanine green tracer-guided lymph node dissection during laparoscopic radical gastrectomy in patients with gastric cancer efficiently harvest more lymph nodes than conventional lymph node dissection?

Findings  In this randomized clinical trial of 266 patients with gastric adenocarcinoma, more retrieved lymph nodes and lower lymph node noncompliance were observed in patients in the indocyanine green group compared with those in the non–indocyanine green group, with a comparable recovery process.

Meaning  Indocyanine green can help surgeons harvest more lymph nodes than conventional lymph node dissection and reduce lymph node noncompliance in patients with gastric cancer who undergo D2 lymphadenectomy, and indocyanine green fluorescence imaging can be used for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy.

Abstract

Importance  The application of indocyanine green (ICG) imaging in laparoscopic radical gastrectomy is in the preliminary stages of clinical practice, and its safety and efficacy remain controversial.

Objective  To investigate the safety and efficacy of ICG near-infrared tracer-guided imaging during laparoscopic D2 lymphadenectomy in patients with gastric cancer.

Design, Setting, and Participants  Patients with potentially resectable gastric adenocarcinoma (clinical tumor stage cT1-cT4a, N0/+, M0) were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital between November 2018 and July 2019. Patients were randomly assigned to the ICG group or the non-ICG group. The number of retrieved lymph nodes, rate of lymph node noncompliance, and postoperative recovery data were compared between the groups in a modified intention-to-treat analysis. Statistical analysis was performed from August to September 2019.

Interventions  The ICG group underwent laparoscopic gastrectomy using near-infrared imaging after receiving an endoscopic peritumoral injection of ICG to the submucosa 1 day before surgery.

Main Outcomes and Measures  Total number of retrieved lymph nodes.

Results  Of 266 participants randomized, 133 underwent ICG tracer-guided laparoscopic gastrectomy, and 133 underwent conventional laparoscopic gastrectomy. After postsurgical exclusions, 258 patients were included in the modified intention-to-treat analysis, which comprised 129 patients (86 men and 43 women; mean [SD] age, 57.8 [10.7] years) in the ICG group and 129 patients (87 men and 42 women; mean [SD] age, 60.1 [9.1] years) in the non-ICG group. The mean number of lymph nodes retrieved in the ICG group was significantly more than the mean number retrieved in the non-ICG group (mean [SD], 50.5 [15.9] lymph nodes vs 42.0 [10.3] lymph nodes, respectively; P < .001). Significantly more perigastric and extraperigastric lymph nodes were retrieved in the ICG group than in the non-ICG group. In addition, the mean total number of lymph nodes retrieved in the ICG group within the scope of D2 lymphadenectomy was also significantly greater than the mean number retrieved in the non-ICG group (mean [SD], 49.6 [15.0] lymph nodes vs 41.7 [10.2] lymph nodes, respectively; P < .001). The lymph node noncompliance rate of the ICG group (41 of 129 patients [31.8%]) was lower than that of the non-ICG group (74 of 129 patients [57.4%]; P < .001). The postoperative recovery process was comparable, and no significant difference was found between the ICG and non-ICG groups in the incidence (20 of 129 patients [15.5%] vs 21 of 129 [16.3%], respectively; P = .86) or severity of complications within 30 days after surgery.

Conclusions and Relevance  Indocyanine green can noticeably improve the number of lymph node dissections and reduce lymph node noncompliance without increased complications in patients undergoing D2 lymphadenectomy. Indocyanine green fluorescence imaging can be performed for routine lymphatic mapping during laparoscopic gastrectomy, especially total gastrectomy.

Trial Registration  ClinicalTrials.gov Identifier: NCT03050879

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