Near-infrared fluorescence angiography for intra-operative assessment of pedicled omentoplasty for filling of a pelvic cavity: a pilot study

M D Slooter,R D Blok,C J Buskens,D D Wisselink,P J Tanis,R Hompes,W A Bemelman

doi:10.1007/s10151-019-02048-0

Abstract

BackgroundDuring creation of a pedicled omentoplasty, blood flow to segments of the omentum might become compromised. If unrecognized, this can lead to omental necrosis. The purpose of this study was to investigate the potential added intra-operative value of the use of fluorescence angiography (FA) with indocyanine green (ICG) to assess omental perfusion.MethodsAll consecutive patients undergoing a pedicled omentoplasty in a 6-month period (April 1 2018–October 1 2018) in a University hospital were included. The primary outcome was change in management due to FA. Secondary outcomes included the amount of additionally resected omentum, added surgical time, and quantitative fluorescent values (time to fluorescent enhancement, contrast quantification).ResultsFifteen patients had pelvic surgery with omentoplasty and FA. Change in management occurred in 12 patients (80%) and consisted of resecting a median of 44 g (range 12–198 g) of poorly perfused omental areas that were not visible by conventional white light. The median added surgical time for the use of FA and subsequent management was 8 min (range 3–39 min). The first fluorescent signal in the omental tissue appeared after a median of 20 s (range 9–37 s) after injection of ICG. The median signal-to-baseline ratio was 23.7 (interquartile range 12.2–29.7) in well perfused and 2.5 (interquartile range 1.7–4.0) in poorly perfused tissue.ConclusionsFA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study. These findings support the conduct of larger studies to determine the impact on patient outcome in this setting.

Highlights

Application of omentoplasty is a well-established option for filling of a presacral cavity after both primary abdominoperineal resection [1] and more complex salvage surgery [2,3,4,5]
Intra-operative partial omental flap necrosis has been reported to occur in up to 10% of cases [6], and post-operative flap necrosis requiring reoperation has been reported in an additional 2–4% [6,7,8]. This suggests that blood flow to segments of the omentum might become compromised after flap creation, implying the need for intra-operative evaluation of omental perfusion with higher sensitivity than conventional white light assessment
The omentoplasty was pedicled on the left gastroepiploic artery in 9 out of 15 (60%) and on the right in 6 out of 15 (40%) cases

Summary

Introduction

Application of omentoplasty is a well-established option for filling of a presacral cavity after both primary abdominoperineal resection [1] and more complex salvage surgery [2,3,4,5]. Intra-operative partial omental flap necrosis has been reported to occur in up to 10% of cases [6], and post-operative flap necrosis requiring reoperation has been reported in an additional 2–4% [6,7,8] This suggests that blood flow to segments of the omentum might become compromised after flap creation, implying the need for intra-operative evaluation of omental perfusion with higher sensitivity than conventional white light assessment. Conclusions FA of a pedicled omentoplasty allows a real-time assessment of omental perfusion and leads to change in management in 80% of the cases in this pilot study These findings support the conduct of larger studies to determine the impact on patient outcome in this setting

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Conclusion