Update Course Rewind: Updates in Indocyanine Green (ICG) 2023

GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello Pediatric Surgery Family. I'm Cecilia Jijena, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held this past August. In this video series, we'll recap the sessions and share the main highlights with you. Today we are talking about updates in ICG. For that, we have Dr. Seth Goldstein, a pediatric surgeon from Lurie Children's Hospital. So, first, let's hear what ICG is. Indocyanine Green was this neat dye that uh that the the post World War II Kodak company found because it's got a really pleasant green and so it's been FDA approved since the 1960s. It's a safe, harmless fluorescent contrast. So, this compound can be injected subcutaneously or intravenously, dependent on the use, and its usage has really developed in hepatobiliary surgery. But today we are learning about other usages for this. Let's start with a case. 10-year-old boy, right gluteal, biopsy confirmed alveolar rhabdo. You've been asked for sentinel node biopsy at the time of port placement. This is pretty much standard of care and so my question for you all is what is your preferred primary marker for sentinel node identification? Normally, for the location of a sentinel node, we will use a radio tracer such as Technetium-99. That will be caught in the node and can be detected with a special detector. But that is not always easy. Takes a buying from oncologists and the surgeons to purchase the machines second of all it takes at least in our institution takes up group to coordinate the tracer injection and the same day operations. So, it takes a lot of hands to be involved in one procedure that's not that common. And but the tracer worked great. So, it seems that using a radio tracer is not as easy as we thought. Let's hear then what Dr. Goldstein propose. Pediatric surgeons can I'm not yet to the point of saying should but can consider use of ICG as an adjunct to sentinel node identification. And so, of course, the main point is to find the node that is your first sentinel drainage and that's ever so important. But ICG can do that in the operating room with equipment you all either either have or are about to have standard in all your laparoscopic towers. And so, indocyanine injection into the tumor and then you can just watch over the course of 45, 60, 75 seconds the ICG head to the sentinel node. This is actually pretty amazing because most of the new laparoscopic towers have an integrated system with a specific mode that can detects ICG. And so it is not necessary to acquire something different from what we already have in the OR. We are at a junction where we are using the ICG as the primary localizer of the sentinel node. And still confirming with the Technetium. Right, let's move to the next case. 16-year-old girl, unresectable hepatocellular carcinoma. Wants a liver transplant, needs clearance of the lung mets. At the time of your thoracotomy, what's your most sensitive and specific method of localization? We all know that for liver transplant due to hepatic carcinomas, we need to have zero metastasis and that lots of the time implicates bilateral lung metastasectomies. Localizing all of them is a challenge. And even though we trust images and our fingers, it's always great to have an adjument like ICG to detect them intraoperatively. This is a trick of understanding ICG, which is exclusively biliary cleared. So, it's hard when you're in and around the liver. But what if you've got liver tissue in another organ space, then instead of giving it when you want it, you give it the day before. It's the only thing left in the chest by the time you get there the next day. So, at the time of thoracotomies such as these, I mean, you can spend the requisite time feeling and looking. And then when you're done, if you've given ICG the day before, you'll find more. But spots like these are also positive on histology. Let's hear about an innovative implementation that he has been working on. I want to tell you that that injectable ICG is not the only future for fluorescents. Think about pelvic tumors and my query to you all was going to be how you like to protect the ureter. So, a right lower quadrant port looking at at the end of a of a debulking with a aortic bifurcation on the screen right. And how look how the ureter has been kept out of harm's way. A case that I'm quite sure would have needed to be done open because of the ureteral proximity to the clearly sticky tumor. That was standard cystoscopy and stent placement. But when the stent is emitting an infrared light that gets picked up by your system, it it's clear as day. So, it's about augmenting the surgeon's visual field and making things safer and better for us. So, let's summarize what we saw today. ICG is a harmless fluorescent contrast that is excreted by the biliary tract. It can be used to detect sentinel nodes in many types of cancer, and we can either use the laparoscopic or open instruments to see it. As it is primary excreted through hepatic cells, given 24 hours in advance, can be very useful to detect hepatocarcinoma lung metastasis. Finally, even though they are still being developed, we see that there are more fluorescent contrast being made for different reasons, such as detecting the urethras. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. GlobalCastMD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.