Abstract
Aims Anastomotic leakage after colorectal surgery is a severe complication. One possible cause of anastomotic leakage is insufficient vascular supply. The aim of this study was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using indocyanine green (ICG)-enhanced fluorescence.MethodsBetween May 2013 and October 2014, all anastomosis and resection margins in colorectal surgery were investigated using fluorescence angiography (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) intraoperatively to assess colonic perfusion prior to and after completion of the anastomosis, both in right and left colectomies.ResultsA total of 107 patients undergoing colorectal laparoscopic resections were enrolled: 40 right colectomies, 10 splenic flexure segmental resections, 35 left colectomies, and 22 anterior resections. In 90 % of cases, the indication for surgery was cancer and high ligation of vessels was performed. Based on the fluorescence intensity, the surgical team judged the distal part of the proximal bowel to be anastomosed insufficiently perfused in 4/107 patients (two anterior, one sigmoid and one segmental splenic flexure resections for cancer), and consequently, further proximal “re-resection” up to a “fluorescent” portion was performed. None of these patients had a clinical leak. The overall morbidity rate was 30 %; one patient undergoing right colectomy had an anastomotic leakage, apparently unrelated to ischemia; there were no clinical evident anastomotic leakages in colorectal resections including all low anterior resections.ConclusionsICG-enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis, possibly affecting the anastomotic leak rate. Larger further randomized prospective trials are needed to validate this new technique.
Highlights
Based on the fluorescence intensity, the surgical team judged the distal part of the proximal bowel to be anastomosed insufficiently perfused in 4/107 patients, and
Based on the fluorescence intensity recorded under NIR light, after injection of indocyanine green (ICG), the distal part of the proximal bowel to be anastomosed was judged to be insufficiently perfused and the surgical team opted for further proximal ‘‘re-resection’’ up to an ‘‘adequate’’ fluorescent part in 4/107 patients (3.7 %) (Fig. 2)
We reported no clinical evident anastomotic leakage in any of the left sided colectomies, including all the low anterior resections
Summary
ICG-enhanced fluorescence was performed in all patients undergoing laparoscopic colorectal surgery between May 2013 and October 2014. Intraoperative ICG-enhanced fluorescence was used to assess colonic perfusion after intestinal resection, prior to and after completion of the anastomosis, both in right and left colectomies. Twenty-five milligrams of ICG was diluted in 10 ml of soluble water, and a bolus of 0.2 mg/Kg was injected intravenously by the anesthesiologist through a peripheral vein after the division of the mesentery and colon, but before anastomosis. Perfusion images were recorded and assessed in real time (Fig. 1). Any information or change in timing and/or quantity of injection as well as any change in the transection line after ICG-enhanced fluorescence injection was recorded. After completion of the anastomosis, another bolus of 0.2 mg/Kg of ICG was injected and a second evaluation of perfusion was made. ICG fluorescence images appeared blue under NIR excitation, while all other tissues appeared black
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