Assessment Of Tissue Perfusion Research Articles

Strategies for prevention and management of partial flap loss or fat necrosis in microvascular autologous breast reconstruction

Partial flap loss (skin involved) or fat necrosis following autologous breast reconstruction remains a dreaded postoperative complication despite significant advances in microsurgical techniques. Several strategies have been proposed in the preoperative and intraoperative period to prevent this complication ranging from preoperative imaging, intra-operative tissue perfusion assessment, appropriate perforator selection (location and number), maximizing inflow and outflow with additional anastomoses and/or pedicles, and minimizing ischemia time. Postoperative management of partial flap loss (when there is skin involvement) and fat necrosis remains a challenge, with very little published data focusing on classification, timing, and techniques. Early intervention versus close observation may depend on multiple patient factors and the degree or volume of necrosis. Secondary intervention options include hyperbaric oxygen therapy, fat aeration with a needle, liposuction, fat grafting, addition of another flap or implant, depending on the nature of the defect. This review summarizes the current evidence for each of these strategies to help the current surgeon understand their options in preventing and managing patients suffering from partial flap loss.

Intra- and Inter-Observer Variability of Quantitative Parameters Used in Contrast-Enhanced Ultrasound of Kidneys of Healthy Cats.

Contrast-enhanced ultrasound (CEUS) is a non-invasive imaging technique which allows qualitative and quantitative assessment of tissue perfusion. Although CEUS offers numerous advantages, a major challenge remains the variability in tissue perfusion quantification. This study aimed to assess intra- and inter-observer variability for quantification of renal perfusion. Two observers with different levels of expertise performed a quantitative analysis of 36 renal CEUS studies, twice. The CEUS data were collected from 12 healthy cats at 3 different time points with a 7-day interval. The inter- and intra-observer agreement was assessed by the intraclass correlation coefficient. Within and between observers, a good agreement was demonstrated for intensity-related parameters in the cortex, medulla, and interlobular artery. For some parameters, ICCinter was considerably lower than ICCintra, mostly when the ROI encompassed the entire kidney or medulla. With the exception of time to peak (TTP) and mean transit time (mTTI), time-related and slope-related parameters showed poor agreement among observers. In conclusion, it may be advised against having the quantitative assessment of renal perfusion performed by different observers, especially if their experience levels differ. The cortical mTTI seemed to be the most appropriate parameter as it showed a favorable inter-observer agreement and inter-period agreement.

Assessment of colorectal anastomosis perfusion with confocal laser endomicroscopy − an experimental study

Introduction: Early diagnosis of complicated healing of colorectal anastomosis can increase the chance for salvage surgery and thus reduce overall morbidity. Confocal laser endomicroscopy (CLE) enables in vivo assessment of tissue perfusion without disturbing its integrity. This experimental study evaluates the potential of CLE for postoperative monitoring of colorectal anastomosis. Methods: A hand-sewn colorectal anastomosis was performed in 9 pigs. The animals were subsequently divided into groups with normal (N=3) and ischemic anastomosis (N=6). Microscopic signs of hypoperfusion were evaluated postoperatively at regular intervals using CLE. Results: Uneven saturation of the images was evident in the group with ischemic anastomosis. The epithelium had inhomogeneous edges and more numerous crypt branching was visible. Tissue oedema quantified as the number of crypts per visual field was already more extensive at the first measurement after induction of ischemia. There was also a significant difference between the values measured before and 10 minutes after ischemia – 8.7±1.9 vs. 6.0±1.1 (p=0.013). Conclusion: Postoperative monitoring of the colorectal anastomosis using CLE enables prompt detection of perfusion disorders.

Educational needs assessment identifying opportunities to improve sepsis care

IntroductionIn 2015, the Centers for Medicare and Medicaid Services developed a national quality bundle for the management of patients with severe sepsis and septic shock (SEP-1). Despite performance improvement measures,...

Intraoperative assessment of bone viability through improved analysis and visualization of dynamic contrast-enhanced fluorescence imaging: technique report.

Bone devitalization is believed to be a critical determinant of complications such as infection or nonunion. However, intraoperative assessment of bone devitalization, particularly in open fractures and infections, remains highly subjective resulting in variation in treatment. Optical imaging tools, particularly dynamic contrast-enhanced fluorescence imaging, can provide real-time, intraoperative assessment of bone and soft tissue perfusion, which informs the tissues' ability to heal and fight infection. We describe a novel technique to apply indocyanine green-based fluorescence imaging, using a device that is frequently used in the operating room to assess skin or flap perfusion in plastic surgery, to assess bone and deep tissue perfusion in three pertinent cases: (1) a chronic infection/nonunion after a Gustilo type 3A tibia fracture (patient 1), (2) an acute Gustilo type 3C tibia open fracture with extensive degloving/soft tissue stripping (patient 2), and (3) an atrophic nonunion of the humerus (patient 3). In all three cases, fluorescence imaging (both time-specific fluorescence and maximum fluorescence) and derived kinetic maps of time-to-peak, ingress slope, and egress slope demonstrated clear spatial variation in perfusion that corresponded to the patient pathogenesis. The impact of this information on patient outcome will need to be evaluated in future clinical trials; however, these cases demonstrate in principle that optical imaging information has the potential to inform surgical practice, reduce the variation in treatment, and improve outcomes observed in these challenging patients.

IBC-Ox24 Routine Oversewing of Staple Lines to Prevent Leaks is Unnecessary in Patients with Normal Iintraoperative Indocyanine Green (ICG) Perfusion Studies Undergoing Sleeve Gastrectomy

Abstract Anastomotic staple line leaks following laparoscopic sleeve gastrectomy is a devastating complication. Gastric ischemia and poor tissue perfusion has been hypothesized to be a contributing factor. Various interventions including oversewing of staple lines are commonly used hoping to decrease staple line leaks. Indocyanine green (ICG) can be used to assess bowel perfusion and anastomotic viability following laparoscopic surgery. 50 consecutive patients underwent laparoscopic sleeve gastrectomy utilizing intravenous administration of ICG to assess tissue perfusion and the need for staple line oversewing. Methods 50 consecutive patients undergoing laparoscopic sleeve gastrectomy were studied intraoperatively after completion of sleeve gastrectomy using intravenous administration of ICG. 7.5 mg of ICG was administered intravenously. Arterial perfusion and end stage tissue perfusion of the completed sleeve gastrectomy was then evaluated. Vascular arterial inflow of the gastric cardia, body and antrum was carefully evaluated both anteriorly and posteriorly for evidence of delayed tissue perfusion or tissue ischemia. Results In all cases the staple line was examined for staple line formation and evidence of poor tissue perfusion using ICG. Both anterior and posterior evaluation was performed of the distal esophagus, gastric cardia, gastric body and antrum. Absence of tissue perfusion in the resected gastric body was used as a comparison control in all cases. ICG perfusion of the gastric cardia, body and antrum was found to be excellent and brisk in all patients. There were no areas of decreased perfusion or tissue ischemia. Oversewing of the staple line was avoided in all cases. Hemostatic clips were deployed as needed for staple line bleeding until there was no evidence of bleeding on visual inspection and final ICG administration. Patients were followed for evidence of leakage or obstruction for 30 days following completion of the sleeve gastrectomy. There were no leaks, there were no deaths. There were no obstructions and no readmissions. There were no complications related to administration of ICG. Average operative time was 48.7 minutes. Conclusions Our series of 50 consecutive sleeve gastrectomies utilizing ICG to assess for tissue perfusion demonstrated no evidence of tissue perfusion deficiencies along the staple line or at the angle of His. Staple line oversewing was not used in any patients. Staple line oversewing in cases without evidence of tissue perfusion deficits on ICG evaluation following sleeve gastrectomy is unnecessary. Further multicenter studies and prospective randomized series are necessary to confirm these initial findings.

Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery

BackgroundIn recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. MethodsA two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. ResultsConsensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20–60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20–30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. ConclusionICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Laparoscopic Nerve-Sparing Radical Parametrectomy for Deep Lateral Parametrial Endometriosis

<h3>Study Objective</h3> To demonstrate the anatomical and technical highlights of nerve-sparing radical parametrectomy for deep lateral parametrial endometriosis (LPE). <h3>Design</h3> Stepwise demonstration of this method with narrated video footage. <h3>Setting</h3> An urban general hospital. LPE may involves ureter, internal iliac vessels, inferior hypogastric plexus, pelvic splanchnic nerves, or sometimes sacral nerve roots. Although LPE is not overly rare, isolation of the autonomic nerves from LPE cannot always be guaranteed. In cases where endometriosis lesions are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except in cases with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to pelvic organ dysfunctions, which seriously affects quality of life. <h3>Patients or Participants</h3> A 38-year-old woman, para 1, presented with a five-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. MRI revealed right ovarian endometrioma with LPE reaching the lateral pelvic wall. <h3>Interventions</h3> Laparoscopic surgery. <h3>Measurements and Main Results</h3> Main outcome measures were releasing from severe pain, avoidance of postoperative morbidity and preservation of fertility. The procedure was performed using 8 steps, as follows: Step 1, adhesiolysis and adnexal surgery; Step 2, complete ureterolysis; Step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; Step 4, dissection of internal iliac vessels; Step 5, identification and dissection of sacral roots S2-S4 and pelvic splanchnic nerves; Step 6, complete removal of LPE; Step 7, hemostasis and assessment of tissue perfusion using ICG; and Step 8, application of barrier agents to prevent adhesion. The patient developed no perioperative complications, including postoperative bladder, rectal or sexual dysfunctions. Pain was completely resolved after surgery. <h3>Conclusion</h3> Laparoscopic nerve-sparing radical parametrectomy is technically safe and feasible for selected patients with LPE. Suitably tailored treatment should be provided for each individual, based on both the latest scientific evidence and life planning for the patient.

Assessing the development status of intraoperative fluorescence imaging for anatomy visualisation, using the IDEAL framework

ObjectivesIntraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: visualising anatomy, assessing tissue perfusion, identifying/localising cancer and mapping lymphatic systems. To establish evidence-based...

Nerve-sparing surgery for deep lateral parametrial endometriosis

Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE). Stepwise demonstration of this method with a narrated video footage. An urban general hospital. A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots. Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure. Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization). The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved. Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.

Xenon-enhanced computed tomography assessment of brown adipose tissue distribution and perfusion in lean, obese, and diabetic primates.

ObjectiveThis study aimed to validate xenon‐enhanced computed tomography (XECT) for the detection of brown adipose tissue (BAT) and to use XECT to assess differences in BAT distribution and perfusion between lean, obese, and diabetic nonhuman primates (NHPs).MethodsWhole‐body XECT imaging was performed in anesthetized rhesus and vervet monkeys during adrenergic stimulation of BAT thermogenesis. In XECT images, BAT was identified as fat tissue that, during xenon inhalation, underwent significant radiodensity enhancement compared with subcutaneous fat. To measure BAT blood flow, BAT radiodensity enhancement was measured over time on the six computed tomography scans acquired during xenon inhalation. Postmortem immunohistochemical staining was used to confirm imaging findings.ResultsXECT was able to correctly identify all BAT depots that were confirmed at necropsy, enabling construction of the first comprehensive anatomical map of BAT in NHPs. A significant decrease in BAT perfusion was found in diabetic animals compared with obese animals and healthy animals, as well as absence of axillary BAT and significant reduction of supraclavicular BAT in diabetic animals compared with obese and lean animals.ConclusionsThe use of XECT in NHP models of obesity and diabetes allows the analysis of the impact of metabolic status on BAT mass and perfusion.

Intraoperative visualization and quantitative assessment of tissue perfusion by imaging photoplethysmography: comparison with ICG fluorescence angiography.

Intraoperative monitoring of tissue perfusion is of great importance for optimizing surgery and reducing postoperative complications. To date, there is no standard procedure for assessing blood circulation in routine clinical practice. Over the past decade, indocyanine green (ICG) fluorescence angiography is most commonly used for intraoperative perfusion evaluation. Imaging photoplethysmography (iPPG) potentially enables contactless assessment of the blood supply to organs. However, no strong evidence of this potential has been provided so far. Here we report results of a comparative assessment of tissue perfusion obtained using custom-made iPPG and commercial ICG-fluorescence systems during eight different gastrointestinal surgeries. Both systems allow mapping the blood-supply distribution over organs. It was demonstrated for the first time that the quantitative assessment of blood perfusion by iPPG is in good agreement with that obtained by ICG-fluorescence imaging in all surgical cases under study. iPPG can become an objective quantitative monitoring system for tissue perfusion in the operating room due to its simplicity, low cost and no need for any agent injections.

Abstract No. 368 Combined assessment of blood flow and tissue perfusion in diabetic feet using intra-arterial 4D contrast CT angiography and perfusion

To employ dynamic computed tomography angiography (CTA) imaging and perfusion (CTP) imaging for improved anatomic and hemodynamic information in patients with foot ulcers for optimal treatment planning using low-volume intra-arterial contrast injections

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine.

There is a risk for thrombotic complications (2 to 5 percent) associated with microsurgical reconstruction. Current thrombolytic therapy has a salvage rate between 60 and 70 percent, but it is afflicted by bleeding complications (2 to 6 percent). The use of machine perfusion for delivering thrombolytic agents is a new method that could potentially reduce these complications. In this article, the authors compared flap salvage outcomes comparing machine thrombolysis versus a manual flush with tissue plasminogen activator. Sixteen bilateral flaps (12 × 9 cm) were dissected from eight female Dutch Landrace pigs (70 kg). Thrombosis was induced in free rectus abdominis flaps by clamping the pedicle's veins for 2 hours. Flaps were either thrombolysed with 2 mg tissue plasminogen activator (1 mg/ml) during 2 hours of machine perfusion (perfusion group; n = 8) or injected intraarterially (manual group; n = 8) before replantation. Near-infrared fluorescence angiography was used to confirm thrombus formation and to assess tissue perfusion; muscle biopsy specimens were analyzed for ischemia/reperfusion injury directly after thrombolysis and 15 hours after replantation. A higher incidence of secondary thrombosis was seen in the manual group compared to the perfusion group ( n = 6 versus n = 0, respectively; p < 0.001), resulting in two complete flap failures. Fifteen hours after replantation, mean fluorescence intensities were 13.0 (95 percent CI, 10.1 to 15.8) and 24.6 (95 percent CI, 22.0 to 27.2) in the perfusion and manual group, respectively ( p < 0.001), and mean muscle injury scores were comparable, measuring 7.5 ± 1.5. Two hours of machine thrombolysis of compromised flaps in a porcine model showed higher salvage rates compared to a manual injection with tissue plasminogen activator and reduced the incidence of secondary thrombosis. Using machine perfusion systems for ex vivo thrombolysis provides the benefits of local treatment of a composite tissue without the risk of systemic complications and may improve salvage rates and reduce the incidence of secondary thrombosis.

A PRE-EXPERIMENTAL STUDY TO EVALUATE THE EFFECTIVENESS OF BUERGER ALLEN EXERCISE ON LEVEL OF LOWER LIMB TISSUE PERFUSION AMONG PATIENT WITH DIABETES MELLITUS ADMITTED IN SELECTED HOSPITAL U.P

The objectives of the study were: (I) To assess the level of lower limb tissue perfusion among patient with diabetes mellitus before and after administration of buerger Allen exercise. (II) To evaluate the effectiveness of buerger Allen exercise on the level of lower limb tissue perfusion among patient with diabetes mellitus. (III) To find out the association between post interventional scores of lower limb tissues perfusion with the selected demographic variables. The Conceptual framework adopted for the study was based on Health Promotion Modal proposed by Nola J. pander in 1992. Quantitative Research Approach was adopted with Pre experimental: one group pre-test - post-test design. The tool used for the date collection demographic variables and Tissue Perfusion Scale with Seven Parameter for assessment of lower limb tissue perfusion. Content validity of the was done by 9 experts from the field of medicine and Nursing. The obtained data was analyzed using both descriptive and inferential statistic in terms of Frequency, Percentage, Mean, and Mean, deference, Standard Deviation, t value and Chi-square. Major finding of the study are majority 43.3% (13) in the age group of 30-40 years. Mean post Tissue Perfusion score was higher than the Mean Tissue Perfusion score. To obtain the difference between pre and post Tissue Per score was found to be statistically significant at 0.05 level of significant. The finding of study revealed that implementation of Buerger Allen Exercise was effective for Improving Level of Lower Limb Tissue Perfusion. Majority of patients were felt relaxed and Buerger Allen Exercise used by the researcher was accepted, Buerger Allen Exercise is non-invasive, non-pharmacological and effective mean which can be used for diabetes mellitus patients as a routine practice. Based on the research finding further recommendation also given.

Imaging PPG for In Vivo Human Tissue Perfusion Assessment during Surgery.

Surgical excision is the golden standard for treatment of intestinal tumors. In this surgical procedure, inadequate perfusion of the anastomosis can lead to postoperative complications, such as anastomotic leakages. Imaging photoplethysmography (iPPG) can potentially provide objective and real-time feedback of the perfusion status of tissues. This feasibility study aims to evaluate an iPPG acquisition system during intestinal surgeries to detect the perfusion levels of the microvasculature tissue bed in different perfusion conditions. This feasibility study assesses three patients that underwent resection of a portion of the small intestine. Data was acquired from fully perfused, non-perfused and anastomosis parts of the intestine during different phases of the surgical procedure. Strategies for limiting motion and noise during acquisition were implemented. iPPG perfusion maps were successfully extracted from the intestine microvasculature, demonstrating that iPPG can be successfully used for detecting perturbations and perfusion changes in intestinal tissues during surgery. This study provides proof of concept for iPPG to detect changes in organ perfusion levels.

Near-infrared fluorescence imaging guided surgery in colorectal surgery.

Near infrared fluorescence using indocyanine green is beneficial for visual assessment of blood vessels, blood flow, and tissue perfusion, sentinel lymph node biopsy, lymph node road mapping, identification of the vascular system round the major vessels, and the detection of ureters in order to reduce the risk of iatrogenic ureteral lesions in colorectal surgery.

High-speed light-sheet microscopy for the in-situ acquisition of volumetric histological images of living tissue.

Histological examinations typically require the excision of tissue, followed by its fixation, slicing, staining, mounting and imaging, with timeframes ranging from minutes to days. This process may remove functional tissue, may miss abnormalities through under-sampling, prevents rapid decision-making, and increases costs. Here, we report the feasibility of microscopes based on swept confocally aligned planar excitation technology for the volumetric histological imaging of intact living tissue in real time. The systems' single-objective, light-sheet geometry and 3D imaging speeds enable roving image acquisition, which combined with 3D stitching permits the contiguous analysis of large tissue areas, as well as the dynamic assessment of tissue perfusion and function. Implemented in benchtop and miniaturized form factors, the microscopes also have high sensitivity, even for weak intrinsic fluorescence, allowing for the label-free imaging of diagnostically relevant histoarchitectural structures, as we show for pancreatic disease in living mice, for chronic kidney disease in fresh human kidney tissues, and for oral mucosa in a healthy volunteer. Miniaturized high-speed light-sheet microscopes for in-situ volumetric histological imaging may facilitate the point-of-care detection of diverse cellular-level biomarkers.

Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery.

Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.

Assessment of Flap Viability for Complex Transmetatarsal Amputation Using Indocyanine Green Fluorescent Angiography: A Case Study.

Despite advancements in the treatment of diabetic patients with "at-risk" limbs, minor and major amputations remain commonplace. The diabetic population is especially prone to surgical complications from lower extremity amputation because of comorbidities such as renal disease, hypertension, hyperlipidemia, microvascular and macrovascular disease, and peripheral neuropathy. Complication occurrence may result in increases in hospital stay duration, unplanned readmission rate, mortality rate, number of operations, and incidence of infection. Skin flap necrosis and wound healing delay secondary to inadequate perfusion of soft tissues continues to result in significant morbidity, mortality, and cost to individuals and the health-care system. Intraoperative indocyanine green fluorescent angiography for the assessment of tissue perfusion may be used to assess tissue perfusion in this patient population to minimize complications associated with amputations. This technology provides real-time functional assessment of the macrovascular and microvascular systems in addition to arterial and venous flow to and from the flap soft tissues. This case study explores the use of indocyanine green fluorescent angiography for the treatment of a diabetic patient with a large dorsal and plantar soft-tissue deficit and need for transmetatarsal amputation with nontraditional rotational flap coverage. The authors theorize that the use of indocyanine green may decrease postoperative complications and cost to the health-care system through fewer readmissions and fewer procedures.