Alberto Mangano, MD, Federico Gheza, MD, Roberto E Bustos, MD, Eleonora M Minerva, Matrovito Sara, Sam Papasotiriou, Liaohai Leo Chen, PhD, Pier C Giulianotti, MD, FACS, Professor of Surgery. UIC, Department of Surgery. Division of General, Minimally Invasive and Robotic Surgery
Introduction: anastomotic leakage in colon/rectal surgery is a dangerous event with an occurance rate ranging from 1-30%.The associated mortality rate is between 6-22%.The white-light intraoperative subjective surgical assessment(the most frequently used approach)underestimates the actual anastomotic leakage rate. Intraoperative tissue perfusion assessment by Indocyanine green(ICG)-enhanced fluorescence has been reported in multiple clinical scenarios in laparoscopic/robotic surgery, as well as for for bowel perfusion assessment. This technology can detect microvascular impairment, potentially preventing anastomotic leakage. We reviewed the literature and present our data to evaluate the feasibility and usefulness of ICG-enhanced ?uorescence in the intraoperative assessment of vascular peri-anastomotic tissue perfusion in colorectal surgery.
Methods and Procedures: A PubMed literature narrative review has been performed. Moreover, out of a total of 164 robotic colorectal cases, we retrospectively analyzed 28 ICG-enhanced fluorescence robotic colorectal resections (15 left colectomies-8 rectal resections-3 right-1 transverse-1 pancolectomy).
Results: After ICG-technology use, the biggest(n>100)case-series showed a rate of 3.7-19% of cases in which they changed the level of resection based on ICG. ICG technology may variably reduce the anastomotic leak rate from 4-12%. However, the threshold values to define the actual sub-optimal perfusion are still under investigation. In our experience, out of 28 ICG cases performed: the conversion, intraoperative complication, dye allergic reactionand mortality rates were all 0%. Post-op surgical complications: 1 case of leak (3,6%) and 1 SBO for incarcerated hernia (3.6%). In 2 cases, with normal white-light assessment, the level of the anastomosis was changed after ICG showed ischemic tissues. Despite the application of ICG, 1 anastomotic leak has been registered.
Conclusions: ICG-enhanced ?uorescence may intraoperatively change the white-light assessed resection/anastomotic level, potentially decreasing the anastomotic leakage rate. Our data shows that this technology is safe, feasibile and may prevent anastomotic leakage. However, the decision making is still too subjective and not data driven. At this stage ICG, beside being a promising technique, doesn’t have high level of evidence(most of the reports are retrospective). Some randomized prospective trials with an adequate statistical power are needed. A precise injection dose and timing standardization is required. The main challange is to develop a method to objectively obtain a real-time intensity assessement. This may provide objective metric tresholds for an intraoperative evidence/data-based surgical decision making.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88158
Program Number: P261
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster