Indocyanine green enhanced fluorescence to assess bowel perfusion during laparoscopic colorectal resection

Luigi Boni, MD, FACS1, Elisa Cassinotti, MD, PhD1, Giulia David, MD1, Abe Fingerhut, MD, FACS, Hon, ASA, Hon, FRCS, Hon, Ed2. 1Minimally Invasive Surgery Center, 2Section for Surgical Research, Department of Surgery Medical University of Graz

Aims: Anastomotic leakage after colorectal surgery is a severe complication. One possible cause of anastomotic leakage is insufficient vascular supply. The aim of this study is to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using indocyanine green (ICG) enhanced fluorescence.

Methods: Between May 2013 and October 2014 all anastomosis and resection margins in colorectal surgery were investigated using fluorescence angiography (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) intraoperatively to assess colonic perfusion prior to and after completion of the anastomosis, both in right and left colectomies.

Results: 107 patients undergoing colorectal laparoscopic resections were enrolled: 40 right colectomies, 10 splenic flexure segmental resections, 35 left colectomies, and 22 anterior resections.  In 90% of cases the indication for surgery was cancer and high ligation of vessels was performed. Based on the fluorescence intensity, the surgical team judged the distal part of the proximal bowel to be anastomosed insufficiently perfused in 4/107 patients (2 anterior, 1 sigmoid and 1 segmental splenic flexure resections for cancer), and consequently, further proximal “re-resection” up to a “fluorescent” portion was performed. None of these patients had a clinical leak. The overall morbidity rate was 30%; one patient undergoing right colectomy had an anastomotic leakage, apparently unrelated to ischemia; there were no clinical evident anastomotic leakages in colorectal resections including all low anterior resections.

Conclusions: ICG enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis, possibly affecting the anastomotic leak rate. Larger further randomized prospective trials are needed to validate this new technique.

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