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Near-infrared surgical navigation system - application of Fluobeam
The near-infrared laser produces deeper tissue penetration than white light, even deeper, smaller targets can be detected, and the autofluorescence of cells and tissues is minimal in the near-infrared, so when detecting complex biological systems , near-infrared dyes provide higher specificity and sensitivity. Near-infrared dyes and near-infrared imaging have become an emerging field that has developed rapidly in recent years. Imaging devices such as radionuclide imaging, positron emission tomography, single photon emission computed tomography, and magnetic resonance imaging are unlikely to be moved to the surgical room, and these imaging devices have some damage to doctors and patients during operation. The infrared surgery real-time imaging system is increasingly favored by surgeons because of its simple operation, non-toxic and harmless, flexible movement, and economical features.
1. Tumor resection real-time guidance :
Every year, more than 5 million cancer patients worldwide undergo tumor surgery, which is currently the most effective cancer treatment program. Reliable and accurate surgical resection can save tens of thousands of patients' lives. In tumor surgery, tumor recognition, the determination of the margin of tumor resection and the identification of metastatic lymph nodes are important factors influencing the prognosis of tumors.
1) Removal of small tumor lesions:
We know that the most thorough treatment for malignant tumors is surgical resection, followed by radiotherapy or chemotherapy. However, after the tumor is removed, it is prone to postoperative metastasis, and the tumor cells are not completely removed. Especially for patients with large tumor metastasis, the traditional surgical resection area is too large to be implemented, and how to completely remove tiny lesions after tumor lymphatic metastasis occurs. The use of fluorescent probes that specifically bind to tumors can clearly distinguish between normal tissues and lesions, providing a scientific basis for accurate tumor resection; fluorescence imaging brings new hope for tumor therapy.
2) Determination of the edge of the tumor resection:
Tumor margin: The shortest distance between the edge of the specimen and the cancer tissue after resection of the primary tumor. It is an important index for evaluating tumor surgery and an important factor affecting tumor prognosis. After using the near-infrared fluorescent dye to specifically label the tumor site, it can be seen that the fluorescent signal has a stronger signal at the tumor margin than the tumor center, which can clearly indicate the tumor boundary and distinguish it from the surrounding healthy tissue. The accuracy of the fluorescent indicator portion was also officially confirmed, and no tumor molecular marker was detected at the margin portion, indicating that the tumor was completely eliminated. Near-infrared fluorescence-guided tumor resection can accurately determine the tumor margin, reduce the damage to healthy tissue, and minimize the patient's pain.
3) sentinel lymph node mapping (Sentinel Lymph Node Mapping)
Malignant tumors are small and difficult to detect, but lymph node metastasis occurs very early. The concept of sentinel lymph node (SLN) was first proposed by Cabanas in 1977. In the case of penile lymphangiography, he found one (or several) lymph nodes that were the first to receive lymphatic drainage from the tumor area and the earliest tumor metastasis, which was named SLN. In the 1990s, a large number of clinical studies found that breast tissue has similar anatomical features of lymphatic drainage. The drainage of the lymph in the breast has a specific regularity, and the lymph in a certain area is first drained to the lymph nodes of one or a few specific areas, namely SLN. In theory, SLN is the first barrier to temporarily prevent cancer cells from metastasis through lymphatics, and is the first stop for lymphatic drainage in breast cancer. If breast cancer SLN has no cancer metastasis, no other lymph nodes in the primary tumor drainage area will metastasize.
Clinical studies have shown that for breast cancer patients without significant axillary lymphadenopathy, the accuracy of detecting SLN in the axillary lymph nodes is >95%. The presence or absence of SLN can accurately reflect the presence or absence of other lymph nodes in the armpit. Clinically, SLN localization and biopsy are performed in patients with breast cancer, and whether or not axillary anatomy is performed according to the presence or absence of SLN metastasis can make patients with SLN negative exempt from blind axillary removal.
It is often difficult to confirm the location of tissues such as lymph nodes in cancer surgery. If a near-infrared "navigation" system is used, the above problem can be solved and the patient treated with minimal resection. The near-infrared light is not visible to the naked eye, but the ultra-high sensitivity camera can capture the weak light of the near infrared. Using the monitor to observe the color image captured by the camera, you can clearly see the glowing blood vessels, lymph nodes and surrounding organs, so as to accurately grasp the position of the relevant tissues and organs and perform surgery. Although the location of lymph nodes and blood vessels can also be confirmed by radiation, this method exposes the patient to weak radiation and the treatment site is therefore limited. The near-infrared and near-infrared dyes are harmless to the human body and can be used multiple times, and the burden on patients is greatly reduced.
2. Lymphatic and lymphatic drainage imaging :
The lymphatic system is closely related to many diseases, such as tumor metastasis, inflammatory response, diabetes, obesity, and asthma . Especially during tumor metastasis, the lymphatic system can transport tissue fluids and cells to the circulatory system, and more and more have been discovered. Tumors use lymphatic catheters to complete metastases, such as breast cancer, melanoma, and head and neck cancer. Therefore, the research and understanding of the lymphatic system is conducive to the study of the mechanism of tumor metastasis. ICG has been successfully used in the biopsy of sentinel lymph nodes such as breast cancer and melanoma. Other near-infrared dyes such as Alexa 705, IRDye780, Cy7, and Cy5.5 can be used for imaging lymphatic drainage.
During the active period of arthritis, many immune factors are activated, inflammatory factors, cytokines, interleukins and some other factors are secreted, promote inflammation, and lead to the destruction of adjacent joint structures, and stimulate neovascularization in the synovial membrane area. The emergence of the microcirculation. The use of near-infrared dyes to image the lymph nodes surrounding the inflammation reveals a large accumulation of fluorescent signals, which can also be used as an intuitive method for early diagnosis of arthritis.
In addition, lymphatic drainage plays a major role in many physiological functions. Animal experiments and clinical studies have found that cervical lymphatic drainage disorder can lead to morphological, physiological and behavioral abnormalities of the brain tissue; lymphatic drainage of the central nervous system (CNS) is involved. The recovery of macromolecular substances, the regulation of intracranial pressure, and the physiological processes such as CNS immunization have also begun to attract attention.
3. ureter tracer (Intraoperative Ureteral Guidance):
In ureteral injury or some surgical procedures, ureteral search is very difficult. Tanaka et al. use white light of 0.5 mW/cm2 400-700 nm, and near-infrared light of 5 mW/cm2725-775 nm, and near-infrared imaging with a spot diameter of 15 cm. system. The study found that injection of 7.5 μg / kg CW800-CA in the pig model can see the ureter in the invisible light, see the foreign body of the ureter with a diameter less than 2.5 mm, retrograde injection of 10 μM ICG can accurately locate the ureteral injury leak point.
4. Intraoperative Near-infrared Fluorescent Cholangiography
The occurrence of residual stones after cholelithiasis is the main reason for biliary reoperation. The advantage of intraoperative cholangiography is to make up for the above-mentioned deficiencies and play a key role in the operation. When the residual stone is found by angiography, the residual stone can be taken out immediately, and the angiography can be checked at any time according to whether the stone is clean or not, until it is clean. In addition, because cholangiography can clearly show the overall appearance of biliary trees, it provides a reliable basis for the correct treatment of lesions. Intraoperative cholangiography has great clinical value in reducing the rate of biliary residual stones, avoiding the common exploration of common bile ducts, guiding the establishment of reasonable surgical procedures, and avoiding bile duct injuries. Tanaka et al. used NIR light and intravenous CW800-CA to display the extrahepatic bile duct in real time without affecting surgery.
5. Application in assisted hepatectomy and liver disease treatment
Aoki et al. can clearly distinguish between segmentation and sub-segmentation of the liver 1 minute after the portal vein injection of ICG, and can be maintained for 10 minutes. The examination was performed on 35 patients with hepatic malignancies who underwent partial hepatectomy. Among them, 33 patients had obvious liver lobe differentiation. This method is effective, reliable and safe.
6. Evaluation of coronary artery bypass surgery
Coronary angiography, also known as coronary angiography, clearly shows that the location of vascular stenosis or obstruction caused by coronary atherosclerosis is the "gold standard" for the diagnosis of coronary heart disease, but it is rarely used in coronary artery bypass surgery. The methods include intraoperative fluorescence imaging (IFI) and transit-time flowmetry (TTFM). Balacumaraswami et al. considered the evaluation of the effect of the Novadaq detection imaging system for coronary artery bypass surgery. IFI is more sensitive than TTFM, and the false positive rate is low [18] .
7. Application of cerebrovascular surgery
Central nervous system surgery to maintain brain tissue perfusion is one of the most important basic principles, if the blood supply is destroyed during surgery, there may be obvious neurological dysfunction after surgery, especially in the operation of cerebrovascular disease, so the development of real-time intraoperative blood Flow assessment techniques are very important to neurosurgeons. As a new method for evaluation of intraoperative cerebral blood flow, near-infrared phthalocyanine green angiography is simple, rapid, and real-time, and has great application prospects.
1) Intracranial arteriovenous malformation (AVM) is a congenital disorder caused by abnormal cerebral vascular development during embryonic period and one of the common vascular malformations in neurosurgery. At present, surgical treatment is one of the most effective treatments for brain AVM. However, the correct judgment of intraoperative lesion boundaries and vascular properties is the key to successful surgery. In addition to the skilled operation techniques and rich surgical experience, some of the intraoperative assistive technologies that emerged with the development of technology have played an increasingly important role. ICG angiography clearly shows arteriovenous shunt and distinguishes AVM arteries, draining veins, and normal cortical arteries that pass through, and this difference is indistinguishable under the operating microscope. However, DSA (digital subtraction angiography, DSA) is still the "gold standard" in AVM surgery. ICGA can be used as an effective aid rather than replacing intraoperative DSA.
2) In the operation of aneurysm, the contrast agent can dynamically delineate the shape of the blood vessel when running with the blood flow, so that the artery, the distal end of the blood vessel, the branch, the penetrating branch can be unobstructed, and whether the aneurysm clipping is accurate can be Obtained intraoperative confirmation, which provides a valuable basis for prognosis evaluation, treatment and so on. ICG intraoperative angiography is a simple and practical angiography technology, which can provide vascular patency and real-time information of aneurysms. It is simple to use, clear and non-radioactive, and is widely used in aneurysm surgery.
3) Application of ICGA in intracranial and extracranial bypass vascular bypass surgery
Wo itzik et al applied ICGA in 45 cases of intracranial and extracranial bypass vascular bypass surgery. A total of 51 ICGAs were performed during the operation. All of them were well-filled after modified anastomosis and were used for postoperative DSA or CT angiography (CTA). Confirmed.
In short, the “navigation†of surgery using real-time imaging of near-infrared fluorescence has begun to be valued by more and more surgeons, and it has become more transmissive, sensitive, and economical, and simple to operate. Features such as easy mobility and so on are also emerging in surgery. As technology continues to mature and develop, it will be a new type of surgical diagnosis and surgical aid.