吲哚菁绿标记的荧光实时显影技术在腹腔镜肾部分切除术中的应用

doi:10.19723/j.issn.1671-167X.2020.04.011

摘要/Abstract

摘要：

目的: 评估吲哚菁绿(indocyanine green,ICG)标记的荧光实时显影技术在腹腔镜肾部分切除术中应用的可行性和效果。方法: 回顾性分析北京大学第三医院在2019年7月至2020年1月由单一术者所行25例患者ICG标记的近红外荧光腹腔镜肾部分切除术的临床资料,通过荧光显影,精准定位肿瘤,辨认切缘,并在实时显像下完整切除肿瘤,其中1例为双肾肿瘤,共进行26例次手术。收集患者围手术期的临床资料进行统计分析,计量资料采用中位数(范围)表示,计数资料采用百分率表示。男19例,女6例,年龄29~77岁,平均年龄54岁,体重指数25.4(20.0~35.4) kg/m²,肿瘤位于肾上极11个(42%)、中部6个(23%)、下极9个(35%),肿瘤大小为2.75 (1.30~5.20) cm,R.E.N.A.L评分为7.5 (5.0~10.0)。肿瘤术前临床分期:T1aN0M0 23个(88.5%),T1bN0M0 2个(7.7%),T2aN0M0 1个(3.8%)。结果: 25位患者共行26例次手术,患者术中注射ICG无过敏、感染等并发症发生,无术中输血和中转开放者,所有手术切缘均阴性。手术时间为136 (50~247) min,热缺血时间为14 (7~30) min。术中估计失血量为50 (10~400) mL,住院日为5.5 (3.0~31.0) d。术后出现肾周血肿1例,尿漏1例,呼吸衰竭伴下肢静脉血栓1例,经相应治疗后均痊愈,其余无严重并发症发生。随访时间为4~10个月,无肿瘤复发和转移。结论: ICG标记的荧光实时显影技术应用于腹腔镜肾部分切除术安全、有效,有助于肿瘤的精准定位和切除。

关键词: 吲哚菁绿, 肾部分切除, 荧光显像, 腹腔镜

Abstract:

Objective: To detail a novel technique for marking renal tumors with intravenous indocyanine green (ICG) during laparoscopic partial nephrectomy, and to investigate the feasibility and safety of this technique with the use of near-infrared fluorescence imaging. Methods: Between July 2019 and January 2020, 25 consecutive cases with renal masses underwent intraoperative ICG tumor marking laparoscopic partial nephrectomy, at the department of urology in Peking University Third Hospital by the same surgeon. The key benefits included quick intraoperative identification of the mass with improved visualization and real-time control of resection margins by the ICG Immunofluorescence imaging technique. Clinical data were prospectively collected in our institutional database. Perioperative, pathological, and clinical outcomes of the partial nephrectomy were assessed. Measurement data with normal distribution and count data were respectively described as M(range) and percentage. Among these cases, 16 cases were male and 9 cases female , The median body mass index was 25.4 (20.0-35.4) kg/m². The average age was 54 (29-77) years. The maximum tumor diameter was 2.75(1.30-5.20) cm. The R.E.N.A.L score was 7.5 (5.0-10.0).The tumor locations were distributed with upper pole (11, 42%), middle (6, 23%), and lower pole (9, 35%).The clinical stages of the tumor were described as follows: T1aN0M0 (23, 88.5%),T1bN0M0(2, 7.7%),T2aN0M0 (1, 3.8%). Results: All the 25 cases were performed 26 times with intraoperative ICG tumor marking laparoscopic partial nephrectomy. There were no allergy,infection and other complications with intravenous indocyanine green. The surgical procedure was successful in all the patients. No conversion and blood transfusion were needed. All the cases of the surgical margin were negative. Overall the operative time was 136 (50-247) min and warm ischemia time was 14 (7-30) min.The estimated blood loss was 50 (10-400) mL and the hospital stay was 5.5 (3.0-31.0) days. One case with perirenal hematoma, one case with urine leak, one with respiratory failure and deep venous thrombosis. All of these cases were cured by the corresponding treatment. The others had no severe complications. There was no tumor recurrence and metastasis during the follow up with 4 to 10 months. Conclusion: ICG marking and near-infrared fluorescence imaging technology has now emerged as a safe, feasible and useful tool that may facilitate laparoscopic partial nephrectomy.

Key words: Indocyanine green, Partial nephrectomy, fluorescence, Laparoscopy

中图分类号:

R737.11

张树栋,洪鹏,王滨帅,邓绍晖,张帆,陶立元,曹财广,胡振华,马潞林. 吲哚菁绿标记的荧光实时显影技术在腹腔镜肾部分切除术中的应用[J]. 北京大学学报（医学版）, 2020, 52(4): 657-662.

Shu-dong ZHANG,Peng HONG,Bin-shuai WANG,Shao-hui DENG,Fan ZHANG,Li-yuan TAO,Cai-guang CAO,Zhen-hua HU,Lu-lin MA. Usefulness of the indocyanine green fluorescence imaging technique in laparoscopic partial nephrectomy[J]. Journal of Peking University (Health Sciences), 2020, 52(4): 657-662.

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参考文献 13

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Variable	Value
Patients, n	25
Age/year, M (range)	54 (29-77)
BMI/(kg/m²), M (range)	25.4 (20.0-35.4)
Gender, n
Male	19
Female	6
Number of tumor	26
Affected side, n
Left	12
Right	14
Tumor distribution, n
Ventral	20
Dorsal	3
Ventral and dorsal	3
Tumor location, n
Upper	11
Middle	6
Lower	9
Previous abdominal surgery, n	8
Maximum diameter of tumor/cm, M (range)	2.75 (1.30-5.20)
Preoperative creatinine/(μmol/L), M (range)	78 (54-126)
Postoperative creatinine/(μmol/L), M (range)	87.5 (49.0-149.0)
ASA score, n
1	7
2	19
R.E.N.A.L score, M (range)	7.5 (5.0-10.0)
3S+f score, M (range)	7 (5-11)
Surgical approach, n
Transperitoneal	4
Retroperitoneal	22
Intraoperative ultrasonography, n	8
Tumor morphological character, n
Cystic	2
Solid	21
Solid and cystic	3

Items	Values
Pathology type, n
Clear cell RCC	21
Papillary RCC	3
Renal oncocytoma	2
Pathologic stage, n
T1a	21
T1b	2
T3a	3
WHO/ISUP classification, n
Ⅰ	3
Ⅱ	13
Ⅲ	8
Involvement of renal capsule, n	1
Involvement of perirenal fat, n	1
Involvement of renal sinus or pelvis, n	2
Overall operative time/min, M(range)	136 (50-247)
WIT/min, M(range)	14 (7-30)
Estimated blood loss/mL, M (range)	50 (10-400)
LOS/d, M (range)	5.5 (3.0-31.0)
Postoperative complications, n
Perirenal hematoma	1
Urine leak	1
Respiratory failure and DVT	1

Variables	r	P
Diameter of tumor vs. warm ischemia time	-0.179	0.383
Diameter of tumor vs. overall operative time	0.051	0.804
Diameter of tumor vs. estimated blood loss	-0.073	0.722
Diameter of tumor vs. length of stay	-0.141	0.491
Overall operative time vs. estimated blood loss	0.646	0.001
Warm ischemia time vs. estimated blood loss	0.138	0.502
Overall operative time vs. length of stay	0.192	0.347