Use of fluorescent angiography in mucosal advancement procedures: a small series

Jacquelyn S Turner, MD, Carolyn Moore, Clarence Clark. Morehouse School of Medicine

Background: Rectal mucosal advancement procedures are commonly used for perianal fistulas and in the setting of circumferential mucosal prolapse. These procedures can have up to a 30% early complication rate with flap separation likely attributed to poor profusion or technical error. Here, we describe two cases where endoscopic florescent angiography and near infrared illumination (NIR) using indocyanine green (ICG) was utilized to assess mucosal flap profusion prior to repairs of complex recurrent anal fistulas and rectal mucosal prolapse.

Methods: Two cases were retrospectively reviewed. To better understand the presentation, management and outcomes surrounding these cases, a literature search was performed.

Results: Case A is a 23-year-old man with HIV and a history of prior incision and drainage procedures for perianal abscesses with seton placement for complex fistula- in-ano. For definitive treatment, two simultaneous full thickness rectal mucosal advancement flaps were performed. Each flap was evaluated by intra-operative NIR and fluorescent angiography using a PINPOINT (Novadaq, Ontario, Canada) device. One flap was angiographically assessed after flap fixation and the other was assessed before flap fixation. Poor perfusion was noted by the PINPOINT device in the former flap and adequate perfusion was noted in the latter flap. Flap separation was noted in the former flap upon post-operative evaluation while adequate healing was noted in the latter flap. Case B, a 35-year-old man with prior laparoscopic sigmoid colectomy with rectopexy for full thickness rectal prolapse, was taken to the operating room for mucosal prolapse repair one year from his original surgery. PINPOINT was utilized to assess perfusion of the mucosal sleeve after mobilization up to the most proximal area of redundant mucosa. Upon evaluation using the PINPOINT device, a clear demarcation was noted for a point of mucosal transection. After the anastomosis was created, perfusion of each end of the anastomosis was re-confirmed with PINPOINT. No known complications were noted on immediate follow up.

Conclusion: Rectal mucosal advancement procedures can be technically challenging especially after complex, recurring diseases due to a compromise of microvascular perfusion. The PINPOINT device is a tool to assess microvascular perfusion in these difficult situations. Ultimately, this angiographic device helps to guide intra-operative decisions to help reduce post-operative complications as it relates to compromised microvascular perfusion and ultimately improve patient outcomes.

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