Endoscopic Near Infra Red Fluorescence Angiography: New Technology Available for Perfusion Assessment During Laparoscopic Surgery

Elisabeth C McLemore, MD, Michael Stamos, MD, Conor Delaney, MD, Anthony Senagore, MD, Sonia Ramamoorthy, MD, Madhulika Varma, MD, Steven Wexner, MD, Joseph Martz, MD, David Margolin, MD, Larson David, MD, Lee Sang, MD

University of California, San Diego; University of California, Irvine; University of California, San Francisco; University of Southern California; Case Medical Center; Cleveland Clinic Florida; Weill Cornell; Mayo Clinic; Ochsner Clinic; Beth Israel

Objective of the technology or device: Fluorescence angiography is a technology that is available and has been utilized in a variety of open and robotic surgical settings including assessment of adequate tumor margin resection, viability of the blood supply in flaps created during reconstructive plastic surgery, and coronary artery bypass. The technology for NIR fluorescence angiography has now been developed for use in laparoscopic procedures.

Technology: Near Infra Red (NIR) fluorescence angiography using the PINPOINT® Endoscopic Fluorescence Imaging System. The system consists of a rigid endoscope, camera and light source optimized for both high definition (HD) white light and near infra red fluorescence images (NIRF). The NIRF images are acquired following administration of an intravenous bolus of indocyanine green (ICG), an agent confined to the vascular space that fluoresces in the NIR light. Perfusion is assessed by qualitative inspection of the NIRF images.

Application: NIR fluorescence angiography using the Laparoscopic NIRF Imaging System during laparoscopic low anterior resection to assess anastomosis tissue perfusion.

Clinical Impact: The system is being utilized to assess tissue perfusion for colorectal anastomosis:

1. Intra-corporeal, laparoscopic assessment of perfusion at the planned division of the proximal colon.

2. Endoluminal assessment of perfusion of the completed anastomosis and the adequacy of blood flow to both sides of the anastomosis.

Preliminary Results: Case Report

A 67 year old male with a uT2N0 rectal cancer located 6 cm from the dentate line underwent a laparoscopic low anterior resection. The laparoscopic NIRF system was utilized to evaluate the perfusion at the planned division of the proximal colon and good perfusion was visualized at the planned division site. A trans-anal specimen extraction was performed and a colonic pouch rectal anastomosis was created that appeared to have good blood supply by the operating surgeon. The laparoscopic NIRF system was utilized to evaluate the perfusion of the colonic pouch rectal anastomosis and the proximal colon was found to have no perfusion with good perfusion in the remaining rectum. The colonic pouch rectal anastomosis was taken down, additional transverse colon was mobilized, and a hand sewn colo-rectal anastomosis was performed with a diverting ileostomy. The post-operative course was uneventful and the patient was discharged home on POD 5. The ileostomy was reversed three months later. There was no stricture or narrowing at the site of the anastomosis and the patient was discharged on POD 2.

Conclusions / Future directions: The incidence of intra-peritoneal anastomotic leaks reported in the literature varies between 0.5% and 30%. Anastomotic leaks following colectomy are associated with multiple factors including adequacy of blood flow to the anastomosis, anastomotic tension, technical difficulties associated with anastomotic creation, and shorter distance from the anal verge. This case demonstrates a stunning divergence in operative assessment of adequate blood supply and actual tissue perfusion using NIR fluorescence angiography. The utility of intraoperative endoscopic assessment of tissue perfusion using the PINPOINT® system is being evaluated in a multicenter clinical trial (PILLAR II-www.clinicaltrial.org).

Session: Poster Presentation

Program Number: ETP061

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