Abstract
ObjectiveNear-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) might help reduce anastomotic leakage (AL) after colorectal surgery. This pilot study aims to analyze whether a relation exists between measured fluorescence intensity (FI) and postoperative inflammatory markers of AL, C-reactive protein (CRP), Intestinal fatty-acid binding protein (I-FABP), and calprotectin, to AL, in order to evaluate the potential of FI to objectively predict AL.MethodsPatients scheduled for anastomotic colorectal cancer surgery were eligible for inclusion in this prospective pilot study. During surgery, at three time points (after bowel devascularization; before actual transection; after completion of anastomosis) a bolus of 0.2 mg/kg ICG was administered intravenously for assessment of bowel perfusion. FI was scored in scale from 1 to 5 based on the operating surgeon’s judgment (1 = no fluorescence visible, 5 = maximum fluorescent signal). The complete surgical procedure was digitally recorded. These recordings were used to measure FI postoperatively using OsiriX imaging software. Serum CRP, I-FABP, and calprotectin values were determined before surgery and on day 1, 3, and 5 postoperative; furthermore, the occurrence of AL was recorded.ResultsThirty patients (n = 19 males; mean age 67 years; mean BMI 27.2) undergoing either laparoscopic or robotic anastomotic colorectal surgery were included. Indication for surgery was rectal—(n = 10), rectosigmoid—(n = 2), sigmoid—(n = 10), or more proximal colon carcinomas (n = 8). Five patients (16.7%) developed AL (n = 2 (6.6%) grade C according to the definition of the International Study group of Rectal Cancer). In patients with AL, the maximum fluorescence score was given less often (P = 0.02) and a lower FI compared to background FI was measured at 1st assessment (P = 0.039). However, no relation between FI and postoperative inflammatory parameters could be found.ConclusionBoth subjective and measured FI seem to be related to AL. In this study, no relation between FI and inflammatory serum markers could yet be found.
Highlights
Materials and methodsThe patients who did not develop Anastomotic leakage (AL) the maximum score of 5 was given in 16 cases (73%), which was significantly more often compared to the AL group (P = 0.02)
5, 6, and 7, the fluorescence intensity (FI) in patients without Anastomotic leakage (AL) was higher at almost all measurements compared to the FI in patients who develop AL. This difference is only statistically significant when we take the background into account and assess the bowel distal from the proximal anastomosis in the 1st assessment (P = 0.039)
Near-infrared fluorescence (NIRF) angiography with indocyanine green (ICG) is used more and more in colorectal surgery as this technique holds the potential to lower the risk for anastomotic leakage [11]
Summary
The patients who did not develop AL the maximum score of 5 was given in 16 cases (73%), which was significantly more often compared to the AL group (P = 0.02) In both the first and third assessment, no significant differences in subjective fluorescence intensity between the patients with and without anastomotic leakage were seen. 5, 6, and 7, the FI in patients without AL was higher at almost all measurements compared to the FI in patients who develop AL This difference is only statistically significant when we take the background into account and assess the bowel distal from the proximal anastomosis in the 1st assessment (P = 0.039) (see Table 7).
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