Fluorescence angiography with indocyanine green (ICG) to evaluate anastomosis in colorectal surgery: where does it have more value?

Abstract

Indocyanine green (ICG) fluorescence angiography (FA) was introduced to provide the real-time intraoperative evaluation of the vascular supply of anastomosis. However, further studies are required to evaluate its advantages in colorectal surgery and to know in which procedure this technology has more value. The aim of the present study is to assess the usefulness of the ICG-FA in the colorectal anastomosis evaluation and to evaluate where it is most useful depending on type of resection performed in terms of change of section line based on the ICG-FA and anastomotic leakage (AL) rates. This is a prospective study. From September 2014 to November 2018, all patients who underwent any colorectal surgical procedure with ICG-FA in our center were enrolled in the study. Based on the type of surgery, patients were grouped in 4 categories: Group A, right hemicolectomy; Group B, segmental resection of the splenic flexure; Group C, left hemicolectomy; and Group D, anterior resection of the rectum. One-hundred-ninety-two unselected consecutive patients were enrolled: 67 in group A, 9 in B, 81 in C, and 35 in D. Change of section line based on ICG-FA occurred in 35 cases (18.2%): 4 in group A (6%), 1 in group B (11.1%), 21 in group C (25.9%), and 9 in group D (25.7%). ALs occurred in 5 patients (2.6%): 2 in group A (3%), 1 in C (1.2%), and 2 in D (5.7%). ICG-FA leads to significantly more changes in the resection line in case of left hemicolectomy followed by anterior resection. FA is a promising optical imaging technique to reduce the AL incidence after colorectal procedures. To confirm this data, further studies with wider sample size and with an objective evaluation of the anastomotic perfusion are required.