Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Sep 15, 2021; 13(9): 1029-1042
Published online Sep 15, 2021. doi: 10.4251/wjgo.v13.i9.1029
Real-time fluorescence image-guided gastrointestinal oncologic surgery: Towards a new era
Elías Martínez-López, Aleix Martínez-Pérez, Sergio Navarro-Martínez, Juan Carlos Sebastián-Tomás, Nicola de'Angelis, Eduardo García-Granero
Elías Martínez-López, Juan Carlos Sebastián-Tomás, Eduardo García-Granero, Department of Surgery, University of Valencia, Valencia 46010, Spain
Elías Martínez-López, Sergio Navarro-Martínez, Juan Carlos Sebastián-Tomás, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia 46017, Spain
Aleix Martínez-Pérez, Faculty of Health Sciences, Valencian International University, Valencia 46002, Spain
Aleix Martínez-Pérez, Nicola de'Angelis, Minimally Invasive and Robotic Digestive Surgery Unit, Miulli Hospital, Acquaviva delle Fonti 70021, Italy
Eduardo García-Granero, Department of General and Digestive Surgery, Hospital Universitario y Politécnico La Fe, Valencia 46026, Spain
Author contributions: Martínez-López E, Martínez-Pérez A and García-Granero E contributed to conception and design of the work; all authors contributed to drafting of the manuscript and critical revision for important intellectual content; All authors approved the final version.
Conflict-of-interest statement: The authors declare no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Aleix Martínez-Pérez, MD, PhD, Faculty of Health Sciences, Valencian International University, Pintor Sorolla 21, Valencia 46002, Spain.
Received: February 22, 2021
Peer-review started: February 22, 2021
First decision: June 14, 2021
Revised: June 14, 2021
Accepted: July 27, 2021
Article in press: July 27, 2021
Published online: September 15, 2021

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.