We thank Dr Rodríguez-Rojo and the co-authors for their interest in our article “Fluorescence and markers in surgery: the future that is approaching”.1 We value your interesting comment positively and the fact that you share with us the idea of the routine and standardised use of fluorescence with indocyanine green (ICG) in breast pathology surgery, with the indications discussed in your letter, either as a tracer for the identification of the sentinel node (BGC) or, with the more widespread use of tissue perfusion assessment, performing ICG fluorescence angiography (AF-ICG).
Regarding the limitation of patients with obesity, this is a factor that has also been observed in a fluorescence cholangiography with ICG when performing a cholecystectomy, since until this adipose tissue is dissected, it does not permit us to adequately visualise the dye.2 Therefore, it would be of great value to be able to develop lines of research to improve the visualisation of fluorescence when the patient’s characteristics are not entirely favourable.
In the identification of the sentinel node for breast cancer, it has been shown that, if fluorescence with ICG is associated with other molecules, such as albumin, it can increase the intensity and time of fluorescence uptake in lymph nodes.3 Likewise, in our experience in colorectal and esophagogastric surgery, lymphatic drainage is adequately observed, so an alternative to avoid contamination of the surgical field mentioned could be to use a camera that captures this drainage and thus avoid sectioning these lymphatic vessels.
With respect to AF-ICG and the limitation of quantifying the dye, there are already several experimental systems and quantification algorithms to improve the subjective interpretation of this technology.4
All these topics have been discussed in a literature review previously published by our group,5 enabling us to deepen our knowledge of the different applications of ICG and thus be able to provide better care for our patients. The use of ICG in breast surgery, a topic at some distance from the activity of our working group, was included in the published article, showing the evidence to be found in the literature at the present time.5
We believe that fluorescence with ICG is a tool that has been demonstrating its advantages as a support in image-guided surgery, so it is of benefit to continue developing lines of research in all surgical areas in order to obtain more evidence and more solid conclusions. In addition, advances in certain specific areas are transferable to other subspecialties, which undoubtedly enriches knowledge and opens up new areas of development and research.
CRediT authorship contribution statementEugenio Licardie: study designs, data acquisition, analysis and interpretation of results, preparation of the manuscript, critical review and approval of the final version of the manuscript.
Salvador Morales-Conde: study designs, data acquisition, analysis and interpretation of results, preparation of the manuscript, critical review and approval of the final version of the manuscript.
