The use of fluorescence for real-time evaluation of organ and tissue vascularization and
lymph node anatomy is a recent technology with potential for the surgical treatment of
cancer. The real-time analysis of tissue vascularization allows immediate identification to
the surgeon of areas with greater or lesser blood circulation, favoring surgical decision
making and prevention of complications related to tissue ischemia (necrosis, dehiscences and
infections). It is a technology with potential application in the areas of Digestive Surgery,
Repairing Plastic Surgery in Oncology, Head and Neck Surgery. In addition, fluorescence can
be used as a method to identify lymph node structures of interest in the oncological
treatment of patients with urologic, gynecological and digestive tumors.
Introduced by Pestana et al. In the late 2000s, the perfusion mapping system through
intraoperative indocyanine assisted laser angiography (SPY Elite System © LifeCell Corp.,
Branchburg, N.J.) had its initial application in repairing surgery after breast cancer
treatment. The method proved to be useful in the prevention of ischemic and infectious
complications in cancer surgery. Pestana, in a prospective clinical series of 29
microsurgical flaps used in several reconstructions, observed a single case of partial loss
of the flap, the present technology having a relevant role in intraoperative decision making.
In the same year, Newman et al. The first application of the system in breast reconstruction
surgery. In an initial series of 10 consecutive cases of reconstruction with microsurgical
flaps, in 4 cases the system allowed the intraoperative identification of areas of low
perfusion, thus changing the surgical procedure. According to the authors, there was a 95%
correlation between indocyanine laser assisted and subsequent development of mastectomy skin
necrosis, with sensitivity of 100% and specificity of 91%. Similarly, Murray et al. Evaluated
the intraoperative perfusion, however, of the areola-papillary complex in patients submitted
to subcutaneous mastectomies with satisfactory results in terms of predictability of
cutaneous circulation. Other authors in larger clinical series and evaluating other
procedures have observed valid results in terms of prevention of complications.
Vascular perfusion of anastomoses and fistulas following bowel surgery for cancer remain a
serious and common complication. These fistulas can be caused by insufficient perfusion of
the intestinal anastomosis. Intraoperative angiography with indocyanine assisted laser can be
used to visualize the blood perfusion following intravenous injection of the indocyanine
green contrast. Several groups reported the ability to assess blood perfusion of the
anastomotic area after bowel surgery. Although they studied retrospectively, Kudszus and
colleagues described a reduction in the risk of revision due to fistula in 60% of patients
whose anastomosis was examined using laser fluorescence angiography compared to historically
paired patients without this method. The same principle can be used to evaluate the tubulized
stomach to be transposed to the cervical region after subtotal esophagectomy.
Currently, fluorescence-guided sentinel lymph node mapping has been studied in breast cancer
as well as investigative character in colorectal cancer, skin cancer, cervical cancer, vulvar
cancer, head and neck, lung cancer, penile cancer, cancer Endometrial cancer, gastric cancer
and esophageal cancer.
These early studies demonstrated the feasibility of this methodology during surgery.
Comparison of laser fluorescence images on blue dyes indicate that fluorescence images can
replace blue dyes because they exceed them due to increased tissue penetration depth and
absence of staining in the patient and cleaning of the operative field.
To date, there are no clinical studies involving intraoperative perfusion mapping and
identification of lymph node structures with the SPY Elite System © system or other platforms
(Pinpoint or Firefly) in Brazil that evaluate the Brazilian population. In an objective way
the influence of this technology as predictive in the better or worse evolution of the
oncologic surgery as well as in the prevention of the local ischemic complications by means
of intraopeal change of conduct