Alfredo D Guerron, MD, Nova Szoka, MD, Shaina Eckhouse, MD, Chan Park, MD, Ranjan Sudan, MD, Keri Seymour, MD, Dana Portenier, MD, Jin Yoo. Duke University
The obesity epidemic continues to grow and the number of bariatric procedures are increasing substantially. Assessment of perfusion is crucial in preventing complications. New technologies are evolving to provide real life assessment of the tissue perfusion. Laparoscopic fluorescence imaging system allows enhanced visualization of blood vessels, lymphatic system, and the biliary tract through the use of indocyanine green (ICG) that emits fluorescent light that is detected by the PinpointTM technology. This modality has been described in various minimally invasive and robotic surgical procedures. The objective of this work is to use PinPoint technology with ICG enhancement to assess the perfusion of tissue in bariatric surgery procedures.
ICG is a water-soluble anionic probe with excitation and emission wavelengths in serum at 778 and 830 nm. The dye is excreted through the liver immediately via first-pass effect, binds to plasma lipoproteins and has been used to show perfusion in various studies. During standard laparoscopic bariatric procedure PinPoint technology with ICG is administered to the patients. Several potential blood supply complication sites are checked to assess for perfusion. ICG is administered multiple times throughout the case, immediately before each perfusion check steps outlined, with subsequent increase in dose to overcome the background of the previous administration.
Blood perfusion sites include: pouch and roux Limb, small bowel and the mesentery division during creation of biliopancreatic limb and the roux limb prior to the Roux-en-Y reconstruction, adjunctive blood supply to the proximal stomach from the right or left inferior phrenic artery, and transverse blood vessels on the lesser curvature on the sleeve tube.
Figure 1a and 1b Gastric and roux limb perfusion prior to anastomosis.
Figure 1c and 1d Roux limb and biliopancreatic limb with impaired perfusion.
Figure 2 a-d Perfusion from accessory hepatic artery
Figure 3 a-d Perfusion of recurrent branch to esophagus from left inferior phrenic artery.
Based on our observation we propose a perfusion assessment of 3 – 8 seconds. 3 to 5 seconds, reassurance of good perfusion. 5 to 8 seconds, possible impaired perfusion. If > 8 seconds, impaired perfusion. The abnormal dye uptake areas resembles impaired perfusion. Perfusion defects require special attention by the surgeon. Several options are available to avoid complications.
Conclusions / future directions:
Near-infrared enhanced imaging with provides a real time assessment of perfusion. Future directions towards routine determination of perfusion in primary cases should be standardize. Our group is currently exploring this technology to perform perfusion preserving dissection, in revision cases and to assess biliary pathology during bariatric operations.