Impact of Routine Fluorescence Angiography in Colorectal Surgery

Deborah S Keller, MS, MD1, Irlna Tantchou, MD2, Matthew Schultzel, DO2, Juan R Flores-Gonzalez, MD1, Sergio Ibarra, MD1, Eric M Haas, MD, FACS, FASCRS3. 1Colorectal Surgical Associates, 2University of Texas Medical Center at Houston, 3Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical School at Houston

Background: Anastomotic leaks represent a major problem in colorectal surgery. In addition to the clinical morbidity and mortality, anastomotic leaks dramatically increase the length of stay, readmission rates, and total costs of care. Fluorescence Angiography allows real-time visualization of bowel perfusion during colorectal resection and may lead to a decreased incidence of anastomotic leak. The utility and feasibility of intra-operative perfusion assessment has been demonstrated in low anterior resection for malignant disease. However, no previous study has assessed the value for routine use. Our goal was to evaluate the intraoperative and postoperative outcomes using Fluorescence Angiography in benign and malignant abdominal resections.

Methods: Fluorescence Angiography was utilized in a prospective series of minimally invasive benign and malignant colorectal procedures from 8/1/14-8/1/15. Right-sided and small bowel resections, and those receiving neoadjuvant chemoradiation were excluded for respective low and high anastomotic leak rates. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcome measures were the impact of fluorescence angiography on the planned resection site, the rate of stoma creation, and postoperative complications.

Results: 70 patients were evaluated. The cohort had 41 (58.57%) men, a mean age of 55.77 years (SD14.21), and mean BMI of 27.25 kg/m2 (4.98). The main diagnosis was diverticulitis (n=23, 32.86%), and the primary procedure performed a low anterior resection (n=29, 41.43%). Procedures were performed through multiport laparoscopic (n=14), robotic-assisted laparoscopic (n=6), and single-incision laparoscopic approaches (n=50). Nine patients had changes in resection margin from poor perfusion on fluorescence angiography- all appeared grossly pink and viable. After revision, all were well perfused on repeat study. Operative times were similar between the revised and unrevised groups (240.49 min [SD86.79] vs. 236.39 [SD87.40], respectively). Three unplanned stomas were created after change in resection margin. Of the 70 patients, only 1 had a postoperative anastomotic dehiscence/ pelvic abscess. This patient had intraoperative revision of the planned anastomotic site, then readmission for percutaneous drainage. There was 1 other readmission in the cohort (dehydration), 1 reoperation (bleeding), and no mortalities.

Conclusions:  Fluorescence angiography showed value in perfusion assessment for a variety of benign and malignant procedures. Almost 13% of patient had unexpected poor perfusion, with great potential advantages for preventing an anastomotic leak. Patients with a change in anastomotic site may require closer postoperative attention. Fluorescence angiography deserves further study for clinical and financial advantages in routine use for colorectal procedures.

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