IBC-Oxford University2023_BJSOral_18The Use of Indocyanine Green (ICG) Fluorescence Angiography in Laparoscopic Roux-en-Y Gastric Bypass for Perfusion Assessment and Structure Visualisation

Abstract

Abstract Introduction Indocyanine green (ICG) fluorescence angiography (FA) has been utilised in bariatric surgery for assessment of tissue perfusion and blood supply in laparoscopic sleeve gastrectomy (LSG). However, there is limited literature on its use in laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to evaluate the use of ICG-FA in LRYGB for qualitative assessment of tissue perfusion and structure identification. These are the first cases utilising ICG-FA in LRYGB to be performed in the United Kingdom. Methods Thirty-five patients (12 male, 34%, 23 females, 66%) with median (IQR) age of 45 (38 – 52) years and preoperative median (IQR) BMI 45 (37 – 49) kg/m2 underwent LRYGB with ICG-FA. ICG was administered intravenously according to an agreed protocol. Karl Storz® Image 1 Rubina system with overlay and monochromatic modes was utilised for perfusion assessment. ICGFA was utilised for qualitative assessment of gastric pouch perfusion before and after linear stapled gastro-jejunal anastomosis and visualisation of key anatomical landmarks. The perfusion pattern was assessed by the operating team based on a ICG scoring system (ICG-S), which ranged from 1 (no perfusion) to 4 (excellent perfusion) based on timing following ICG injection and intensity of fluorescence detected in the anatomical structures. Results From April 2021 to August 2022, 34 patients underwent primary LRYGB with use of ICG- FA. ICG was utilised in one revisional case. No adverse effects to ICG were observed. ICG-S was 4 in 33 patients. (94%). In two patients (6%), operative strategy was modified based on focal area of no perfusion (ICG score 1) in gastric pouch. ICG-FA helped improve operative safety during division of omentum and in recognition of duodeno-jejunal flexure with fluorescence detection in epiploic vessels and inferior mesenteric vein (IMV) respectively. There were no leaks at a median follow up of 9 months. Conclusion ICGFA imaging allows for qualitative assessment of perfusion and identification of critical anatomical landmarks during LRYGB. The technology is safe and its utilisation in LRYGB provides a “real-time image” of gastric pouch perfusion, helping to demonstrate ischaemic or poorly perfused areas with an opportunity to modify operative strategy.