Camila B Ortega, MD, Alfredo D Guerron, MD, Jin Yoo, MD. Duke University Health System. Department of Surgery. Division of Metabolic and Weight Loss Surgery.
Introduction: The purpose of the study was to describe the use of intraoperative Indocyanine Green (ICG) fluorescence angiography to identify the blood supply patterns of the stomach and gastroesophageal junction (GEJ). We hypothesized that identifying these vascular patterns may help modifying the surgical technique to prevent ischemia-related postoperative leaks.
Methods: 86 patients underwent laparoscopic SG and were examined intraoperatively with ICG fluorescence angiography at an academic center from January 2016 to September 2017. Prior to the construction of the SG, 1mL of ICG was injected intravenously and Pinpoint® technology was used to identify the blood supply of the stomach. Afterwards, the SG was created with attention to preserving the identified blood supply to the GEJ and gastric tube. Finally, 3mL of ICG were injected and Pinpoint® technology was used again to ensure that all the pertinent blood vessels were preserved.
Results: 86 patients successfully underwent the procedure with no complications. The following blood supply patterns to the GEJ were found:
|Right side dominant||20%||
Left Gastric Artery
|Right side accessory||36%||
Accessory artery in the gastrohepatic ligament:
Left side accessory
Left side accessory + Accessory Gastric Artery
|Tributaries form the Left Inferior Phernic Artery singnificantly contributing to the right-sided supply.|
The incidence of overall accessory blood supply to the right-side dominant pattern was more common than expected. In about half of the cases where an accessory vessel was found in the gastrohepatic ligament, the blood flow was toward the stomach (and not the liver). Furthermore, the incidence of accessory blood supply from the left side was found in 34% of the cases. 10% of patients had both the left side accessory and accessory gastric artery pattern. In these particular patients, if a concurrent hiatal hernia repair is performed, these accessory blood supplies are at risk of being injured if care is not taken to preserve them, rendering the GEJ relatively ischemic.
Conclusion: ICG fluorescence angiography allows determining the major blood supply to the proximal stomach prior to any dissection during sleeve gastrectomy so that an effort can be made to avoid unnecessary injury to these vessels.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86388
Program Number: P583
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster