Prediction of anastomotic failure due to poor blood circulation by the HyperEye Medical SystemTM

Michiya Kobayashi, MD, PhD, Takayuki Sato, MD, PhD, Hiromichi Maeda, MD, PhD, Ken Okamoto, MD, PhD, Takeki Sugimoto, MD, PhD, Ken Dabanaka, MD, PhD, Tsutomu Namikawa, MD, PhD, Kazuhiro Hanazaki, MD, PhD. Kochi Medical School

INTRODUCTION: We developed a new imaging system — the HyperEye Medical SystemTM (HEMS; Mizuho Medical Co, Tokyo, Japan) — that enables simultaneous capture of near-infrared (NIR) indocyanine green (ICG) fluorescence and visible light rays through a unique highly sensitive charge-coupled device sensor coated with arrays of red-, green-, blue-, and NIR-specific filters. Unlike multiple-sensor systems, HEMSTM enables real-time color NIR imaging during ICG fluorescence-guided endoscopic surgery without the need for special video data processors to superimpose NIR images on color images. At SAGES 2013, we described the use of this system to monitor blood supply to the proximal colon during laparoscopically assisted low anterior resection. We have since treated a patient with anastomotic failure due to poor blood circulation, which was predicted by HEMSTM during surgery.

METHODS AND PROCEDURE: A 70-year-old woman who had descending colon cancer underwent a left colectomy. The patient had previously undergone a sigmoidectomy for sigmoid colon cancer and a right colectomy for ascending colon cancer. We used HEMSTM during the left colectomy. After mobilization of the left colon and division of the artery laparoscopically, a small laparotomy was made. We injected 5 mL ICG solution (0.5 mg/mL) intravenously. ICG fluorescence was then detected extracorporeally using HEMSTM.

RESULTS: HEMSTM usually reveals clear arterial blood supply approximately 20 seconds after ICG injection. However, HEMSTM did not show the arterial phase of the proximal colon in this case, and it showed the capillary phase over 60 seconds after injection. After confirmation of a delayed blood supply to the proximal and distal colon, a hand-sewn anastomosis was created. The patient experienced severe abdominal pain and a computed tomography scan revealed anastomotic failure 4 days after the surgery. The patient underwent re-operation, which revealed that some of the colon was a dark color. This part was resected and re-anastomosed.

CONCLUSIONS: Using HEMSTM, we were able to visualize ICG fluorescence at sufficient resolution while the surgical field was under regular light. Our findings show that delayed blood supply detected by HEMSTM could indicate poor blood supply and result in anastomotic failure.

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