Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era

Abstract

Technological improvements are crucial in the evolution of surgery. Real-time fluorescence-guided surgery (FGS) has spread worldwide, mainly because of its usefulness during the intraoperative decision-making processes. The success of any gastrointestinal oncologic resection is based on the anatomical identification of the primary tumor and its regional lymph nodes. FGS allows also to evaluate the blood perfusion at the gastrointestinal stumps after colorectal or esophageal resections. Therefore, a reduction on the anastomotic leak rates has been postulated as one of the foreseeable benefits provided by the use of FGS in these procedures. Although the use of fluorescence in lymph node detection was initially described in breast cancer surgery, the technique is currently applied in gastric or splenic flexure cancers, as they both present complex and variable lymphatic drainages. FGS allows also to perform intraoperative lymphograms or sentinel lymph node biopsies. New applications of FGS are being developed to assist in the detection of peritoneal metastases or in the evaluation of the tumor resection margins. The present review aims to provide a general overview of the current status of real-time FGS in gastrointestinal oncologic surgery. We put a special focus on the different applications of FGS, discussing the main findings and limitations found in the contemporary literature and also the promising near future applications.

Keywords: Surgery, Colorectal cancer, Esophageal cancer, Fluorescence, Image-guided surgery, Anastomotic leak, Lymph node

Core Tip: The continuous improvements on the postoperative and the oncological outcomes of patients undergoing gastrointestinal cancer surgery has focused the efforts of the whole surgical community during the last decades. Fluorescence-guided surgery is currently being developed and implemented in many countries and centers with promising expectancies. Fluorescence-guided surgery has the potential to reduce anastomotic leak rates of colorectal or esophagogastric surgery. Moreover, this new technology provides intraoperative real-time lymph node mapping and detection of sentinel lymph nodes or occult peritoneal metastases.