Intraoperative Indocyanine Green Fluorescence Research Articles

Successful laparoscopic resection of gastric lymphangioma under the intraoperative guidance of indocyanine green fluorescence imaging: A case report

Gastric lymphangioma (GLA) is an extremely rare tumor without an established therapeutic strategy. Surgical resection is considered the mainstay of treatment, although there is a high risk of local recurrence if negative margins are not achieved. A 51-year-old man underwent routine abdominal ultrasonography, which incidentally detected a 20-mm tumor adjacent to the lesser curvature of the stomach. GLA was suspected based on its polycystic appearance. After a 16-month monitoring period, laparoscopic resection was performed because of tumor growth and involvement of the left gastric artery. Intraoperative indocyanine green (ICG) navigation system revealed lymphatic drainage from the tumor, which we used to help determine the optimal excision line and minimize the loss of gastric volume. Pathological examination confirmed complete resection with negative margins and supported a diagnosis of lymphangioma. We performed laparoscopic radical resection of GLA under guidance from intraoperative ICG fluorescence imaging, which allowed us to maximize residual gastric volume.

The Efficacy of Intraoperative Fluorescent Imaging Using Indocyanine Green for Cholangiography During Cholecystectomy and Hepatectomy.

PurposeBile duct injury is one of the most serious complications of laparoscopic cholecystectomy. Intraoperative indocyanine green (ICG) cholangiography is a safe and useful navigation modality for confirming the biliary anatomy. ICG cholangiography is expected to be a routine method for helping avoid bile duct injuries.Patients and MethodsWe examined 25 patients who underwent intraoperative cholangiography using ICG fluorescence. Two methods of ICG injection are used: intrabiliary injection (percutaneous transhepatic gallbladder drainage [PTGBD], gallbladder [GB] puncture and endoscopic nasobiliary drainage [ENBD]) at a dosage of 0.025 mg during the operation or intravenous injection with 2.5 mg ICG preoperatively.ResultsThere were 24 patients who underwent laparoscopic cholecystectomy and 1 patient who underwent hepatectomy. For laparoscopic cholecystectomy, the average operation time was 127 (50–197) minutes, and estimated blood loss was 43.2 (0–400) g. The ICG administration route was intravenous injections in 12 cases and intrabiliary injection in 12 cases (GB injection: 3 cases, PTGBD: 8 cases, ENBD:1 case). The course of the biliary tree was able to be confirmed in all cases that received direct injection into the biliary tract, whereas bile structures were recognizable in only 10 cases (83.3%) with intravenous injection. The postoperative hospital stay was 4.6 (3–9) days, and no postoperative complications (Clavien–Dindo ≧IIIa) were observed. For hepatectomy, a tumor located near the left Glissonian pedicle was resected using a fluorescence image guide. Biliary structures were fluorescent without injury after resecting the tumor. No adverse events due to ICG administration were observed, and the procedure was able to be performed safely.ConclusionICG fluorescence imaging allows surgeons to visualize the course of the biliary tree in real time during cholecystectomy and hepatectomy. This is considered essential for hepatobiliary surgery to prevent biliary tree injury and ensure safe surgery.

Indocyanine green fluorescence-guided laparoscopic colorectal cancer surgery with prophylactic retrograde transileal conduit ureteral catheter placement after previous total cystectomy: a case report

BackgroundIatrogenic ureteral injury (UI) is a potentially serious complication of colorectal cancer surgery. Performing perioperative placement of ureteral stents or intraoperative fluorescence navigation surgery for the ureter using indocyanine green (ICG) has been employed as a method of preventing UI. However, transileal conduit stent placement has been considered challenging because it is difficult to identify the ureteral orifice due to the anatomical changes caused by a previous surgery. We report a case in which laparoscopic colectomy was safely performed using a combination of prophylactic transileal conduit ureteral catheter placement and intraoperative ICG fluorescence navigation surgery.Case presentationA 75-year-old man presented to our hospital complaining of vomiting and abdominal distension. He had a history of open total cystectomy and ileal conduit urinary diversion 11 years prior to admission. Computed tomography confirmed colon dilation with fecal impaction from the ascending colon to the sigmoid colon and wall thickening in the sigmoid colon. Colonoscopy during the transanal ileus tube insertion revealed a Borrmann type II tumor with circumferential stenosis 10 cm distal to the junction between the descending colon and the sigmoid colon. The patient was diagnosed with colorectal ileus due to obstructive sigmoid colon cancer and underwent transanal ileus tube insertion. Severe intra-abdominal adhesions were expected due to the previous total cystectomy, and the left ureter was near the sigmoid colon tumor; therefore, prophylactic retrograde transileal conduit ureteral catheter placement was performed one day before the elective surgery.During the operation, 20 ml (5.0 × 10–2 mg/ml) ICG was administered from the transileal conduit ureteral catheter, and ICG fluorescence of the ureter was observed in the retroperitoneum. Laparoscopic Hartmann's operation was successfully performed, confirming ureter fluorescence. The operation time was 231 min, with 5 mL of intraoperative bleeding. The ureteral catheter was removed 3 days after the operation. The patient’s postoperative course was good with no complications, and he was discharged on postoperative day 7.ConclusionsProphylactic transileal conduit ureteral catheter placement and ICG fluorescence navigation surgery were effective in performing laparoscopic colorectal surgery with severe adhesions after urinary diversion.

Efficacy of intraoperative ICG fluorescence imaging evaluation for preventing anastomotic leakage after left-sided colon or rectal cancer surgery: a propensity score-matched analysis.

Intestinal perfusion at the anastomotic site is thought to be one of the most influential risk factors for postoperative anastomotic leakage (AL). We evaluated the efficacy of indocyanine green (ICG) fluorescence imaging at the stump of the proximal colon in left-sided colectomy or rectal resection in terms of decreasing the incidence of AL. Prospectively collected data were retrospectively evaluated. Patients who underwent left-sided colectomy or rectal resection were enrolled (ICG group; n = 197), and patients who had undergone a similar procedure before the ICG group were enrolled from the charts as historical controls (HC group; n = 187). After ICG evaluation, anastomosis was performed where fluorescence was sufficient. The incidence of AL was compared between the ICG and HC groups. Propensity score (PS)-matched data were analyzed to clarify the risk of AL. AL occurred in 6 patients (3.3%) in the ICG group and 17 (10.7%) in the HC group. ICG evaluation revealed 179 patients with good fluorescence and 18 with poor/none perfusion (9.1%). The transection line was changed in all patients with poor/none fluorescence. Three of these 18 patients developed AL (16.7%), though transection line was changed at which is thought to be good. We hope AL in poor/none fluorescence can be prevented at the same rate of cases with good fluorescence. Actually, the rate of that was significantly higher compared with good fluorescence patients (P = 0.038). 93 patients in each group were compared by PS-matched data analysis, which showed the AL rate in the ICG group was significantly lower than that in the HC group (3.2% vs 10.8%, respectively; P = 0.046). Even though this study has limitations of comparison of data prospectively collected and retrospectively analyzed, intraoperative ICG fluorescence imaging evaluation could significantly decrease the incidence of AL.

Intraoperative ICG Fluorescence Allows for Improved Accuracy in Lymph Node Harvest in Robotic Gastric Cancer Surgery

Introduction: Gastric cancer surgery requires adequate margin negative resection along with loco regional D1 and D2 lymphadenectomy. Traditionally, associated morbidity limited performance of D2 lymphadenectomy. Current technology utilizing robotic assisted techniques has allowed for safe performance of D2 lymphadenectomy. We describe using IndocyanineGreen (ICG) fluorescence technique to improve lymph node harvest and increase accuracy.

Laparoscopic right posterior sectionectomy for HCC in cirrhotic liver: ICG for tumor enhancement and negative counter-staining of the transection plane

Background: The importance of anatomical reactions in liver cancer surgery is well known since the first description by Makuuchi in 1985, but its technical difficulty is equally known because of the absence of a clear demarcation of the hepatic segments during parenchymal transection. Takasaki et al. proposed a new concept of anatomical resection in which the Glissonean pedicles can be transected extrahepatically to identify the boundaries of the intersegmental planes. Based on these concepts, intraoperative Indocyanine-Green (ICG) fluorescence can be used to obtain a positive or negative staining of the segments to be resected. Methods: A 54-year-old male patient with well-compensated HCV-related cirrhosis underwent right posterior sectionectomy for a large HCC. 96h before surgery he was injected with 0.5 mg / kg of ICG to achieve intraoperative tumor enhancement. Surgical procedure starts with the preparation of the Pringle maneuver and the mobilization of the right liver. Then, to perform a formal anatomical resection with the so called Glissonean approach, we started the parenchymal dissection at the level of the De Rouvière sulcus, which allows to identify and isolate the portal branch of the right lateral posterior sector. This is then ligated with hemolocks and sectioned. Then 0,05 mg/kg of ICG were intravenously administrated. Results: A negative counter-staining of the transection plane for the right posterior sectionectomy was visualized. The sharp contrast between the dark area (segment 6-7) and the area highlighted in fluorescent green guided the parenchymal transection, allowing to obtain a true anatomical resection. Furthermore, a final check of the transection line was performed, and it turned out to be wrong in the lower portion, where the parenchymotomy was initially carried out without the use of indocyanine green fluorescence guidance. In this way, a re-assessing and a correction of the section line was carried out. Conclusions: The quality of the surgical act has greatly benefited from the use of ICG fluorescence, allowing to obtain a better visualization of the cancerous lesion, best resection margins, better quality specimen. The use of ICG can facilitate a technically complex procedure, through a visual immediacy that gives a real-time feedback on the goodness of the procedure, even allowing to correct a wrong transection plance and making the surgery more didactic.

Application of Indocyanine Green Fluorescence Imaging in Laparoscopic Liver Surgery

To study the clinical use of indocyanine green(ICG)fluorescence imaging in laparoscopic liver surgery, the clinical and pathological data of 68 patients who underwent laparoscopic hepatectomy using the ICG fluorescence imaging technique during the study period from September 2016 to October 2018 in Zhongnan Hospital of Wuhan University were retrospectively analyzed. Analysis was carried out on the surgical methods, fluorescence navigation methods, ICG injection time and dose, tumor characteristics, and pathological studies of the resected specimens. Of 68 patients, only 3 patients were converted to open surgery. 32 patients underwent ICG fluorescent guided laparoscopic anatomical resection of lower hepatic segment/hepatic hemilivers(positive staining in 17 patients, negative staining in 15 patients), with 19 patients successfully staining with ICG(59.4%). Postoperative histopathology showed primary hepatic solid tumors(n=31), secondary liver tumors(n=12), hepatic cysts(n=4), hepatic hemangiomas(n=5), hepatolithiasis(n=12)and hepatic focal nodular hyperplasia(n=1). These lesions were combined with hepatitis B liver fibrosis in 29 patients. ICG fluorescence imaging positively impacted on laparoscopic liver surgery. Proper preoperative ICG injection was helpful for the identification, localization and intraoperative surgical guidance of tumors, especially for patients with deep-seated and central tumors. As a consequence, oncological and surgical safety of laparoscopic liver surgery was improved. Targeted visualization of liver segments and surgical navigation using intraoperative ICG injections facilitated accurate and precise resection of anatomical liver segments or hemi-hepatectomies. The use of intraoperative ICG fluorescence technology for hepatic hemangioma, hepatic cyst, intrahepatic bile duct stones and other benign liver lesions, helped to improve safety of surgery.

Anastomosis Leak: Is There Still a Place for Indocyanine Green Fluorescence Imaging in Colon-Rectal Surgery? A Retrospective, Propensity Score-Matched Cohort Study.

Anastomotic leakage (AL) represents one of the most relevant complications of colorectal cancer surgery. The aim of this study was to evaluate the utility of intraoperative indocyanine green (ICG) fluorescence imaging in the prevention of AL during laparoscopic colorectal surgery. Methods. We retrospectively analyzed 272 patients who underwent rectal and left colon surgery, consecutively enrolled between 2015 and 2019. Due to the heterogeneity of our groups, a propensity score matching (PSM) was performed with a 1:1 PSM cohort. Results. AL occurred in 36 (13.2%) patients. One hundred seventy-seven (65%) of them underwent an intraoperatory ICG test (ICG-group), whereas 95 patients (35%) did not receive the intraoperatory ICG test (no-ICG group). AL occurred in 10.8% of ICG group patients and in 17.8% of no-ICG group patients (P = 0.07). The ICG group registered significantly less type B and type C fistulas than the no-ICG group (57.9 vs 88.2%; P = .043). After PSM, the overall AL rate was less in the ICG group than the no-ICG group (9.3% vs 16%; P = 0.058), while type B and type C fistulas occurred in 5.48% in the ICG group vs 13.70% in the no-ICG group (P = 0.09). Univariate analysis demonstrated a protective effect of intraoperative ICG imaging against AL occurrence (odds ratio (OR: 0.66)). Conclusions. Hypoperfusion is a well-recognized cause of AL. The ICG assessment of colic vascularization is a simple, inexpensive, and side effects free method, which can sensibly reduce both overall AL and type B and type C fistulas when routinely used.

Intraoperative Indocyanine Green Fluorescence Angiography Is Sensitive for Predicting Postoperative Wound Complications in Soft-Tissue Sarcoma Surgery

Indocyanine green (ICG) angiography is a novel technology that has been predictive of postoperative wound complications. It is unknown whether this technology can successfully predict complications after sarcoma resection. In this study, we aimed to evaluate the sensitivity and specificity of ICG angiography in predicting postoperative wound complications after soft-tissue sarcoma resection. A prospective cohort study of 23 patients was performed beginning October 2017 at our institution. Patients who underwent soft-tissue sarcoma resection were included. After tumor resection and wound closure, evaluation of tissue perfusion in skin edges was performed with ICG angiography. Wound complications were recorded in the postoperative follow-up. Eight patients developed postoperative wound complications. Six patients were predicted to have wound complications on the final ICG scans. The accuracy of ICG angiography was dependent on the anatomic location, with improved accuracy in the lower extremity. ICG angiography had a sensitivity of 50%, a specificity and a positive predictive value of 100%, and a negative predictive value of 70% for wound complications after soft-tissue sarcoma resections located in the lower extremity. ICG angiography has a high predictive value in the lower extremity for postoperative wound complications. Level III, Diagnostic.

Does intraoperative indocyanine green fluorescence angiography decrease the incidence of anastomotic leakage in colorectal surgery? A systematic review and meta-analysis.

Colorectal anastomoses in patients with colorectal cancer carry a high risk of leakage. Indocyanine green fluorescence angiography (ICG-FA) is a new technique that allows surgeons to assess the blood perfusion of the anastomosis during operation. This meta-analysis aimed to evaluate whether ICG-FA could prevent anastomotic leakage (AL) in colorectal surgery. Four databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched to identify suitable literatures until March 2020 that compared AL rates between intraoperative use and non-use of ICG-FA in colorectal surgery for cancer. The Review Manager 5.3 software was used to perform the statistical analysis. Evaluation of articles quality and analysis for publication bias were also conducted. Thirteen studies of 4037 patients were included in the meta-analysis. The study included 1806 patients in the ICG group and 2231 patients in the control group. The pooled incidence of AL in ICG group was 3.8% compared with 7.8% in control group. There was a significant difference in AL rate with or without use of ICG-FA (OR 0.44; 95% CI 0.33-0.59; P < 0.00001). Reoperation rates were 2.6% and 6.9% in ICG and control groups, respectively. Application of intraoperative ICG-FA was associated with a lower risk of reoperation (OR 0.39; 95% CI 0.16-0.94; P = 0.04). Overall complication rate was 15.6% in the ICG group compared with 21.2% in the control group. Overall complications were significantly reduced when using ICG-FA (OR 0.62; 95% CI 0.47-0.82; P = 0.0008). Mortality rate was not statistically different with or without the use of ICG-FA (OR 1.22; 95% CI 0.20-7.30; P = 0.83). The results revealed that ICG-FA reduced risks of AL, reoperation, and overall complications for colorectal cancer patients undergoing colorectal surgery. Well-designed RCTs are needed to confirm the usefulness of intraoperative ICG-FA for preventing surgical complications like AL and reoperation.

The efficacy of intraoperative ICG fluorescence angiography on anastomotic leak after resection for colorectal cancer: a meta-analysis.

The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak. Present authors conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective nonrandomized trials, and retrospective trials up to March 2020. Eleven papers fulfilling the screening criteria were included. Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis. The primary outcome measure was AL rate with at least 3 months of follow-up. Secondary outcome measure was operation time, postoperative complications, surgical site infection, reoperation, and ileus rate. The results were analyzed using STATA 12.0 software (Stata Corp, College Station, TX, USA). A total of 3137 patients were collected in 11 studies. Meta-analysis showed that compared with conventional surgery, the ICG fluorescence angiography resulted in a fewer AL rate (OR = 0.31; 95% CI 0.21 to 0.44; P < 0.0001), postoperative complications (OR = 0.70; 95% CI 0.51 to 0.96; P < 0.025), and reoperation rate (OR = 0.334; 95% CI 0.16 to 0.68; P = 0.003). Operation time (weighted mean difference - 25.162 min; 95% CI - 58.7 to 8.375; P = 0.141), surgical site infection rate (OR = 1.11; 95% CI 0.59 to 2.09; P = 0.742) did not differ between the two groups. The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal cancer resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

Background:The contralateral lateral section (zone IV) of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is generally removed intraoperatively. The border of zone IV is usually identified anatomically using the Hartrampf classification. In this study, we used the indocyanine green (ICG) fluorescence method to determine the border of zone IV and find the correlation with clinical flap outcome.Methods:The study recruited breast cancer patients who underwent a pedicled TRAM flap reconstruction. The border of zone IV was identified using the intraoperative ICG fluorescence imaging. The medial border of the removed specimen was sent for a pathological examination of vascular density.Results:A total of 29 patients underwent a pedicled TRAM reconstruction. In 16 patients, the border of zone IV identified by ICG fluorescent imaging was identical to the anatomical border. The ICG imaging showed distinct perfusion patterns, which we divided into 4 categories: sequential, simultaneous, low midline scar, and delayed pattern. Overall, there were no patient with total flap loss, 1 patient had a partial flap loss and 4 patients had a fat necrosis. Neither the ICG perfusion time nor the pathological vascular density correlates with the clinical flap outcome. The delayed ICG perfusion pattern (category IV) has the highest fat necrosis rate, although it is not statistically significant.Conclusions:In this study, more than half of the patients have ICG perfusion corresponding with the Hartrampf zone, which reflected the conventional practice of zone IV pedicled TRAM flap removal. Some ICG perfusion patterns could be helpful, especially in low midline and delayed pattern.

Lymphatic Vessels Mapping in the Lower Extremities of a Healthy Asian Population

Purpose: Intraoperative indocyanine green (ICG) lymphography is an effective tool to obtain real-time video images of functioning lymph vessels in edematous limbs. However, it is difficult to identify the course of lymph vessels in obese patients or patients with large dermal backflow. Without the image, surgeons have to rely on their experience when performing the skin incision to locate the lymphatic vessels. This study focused on elucidating lymphatic vessel flow patterns in healthy lower extremities in an Asian population to refer these findings for lymphedema treatment.Methods: ICG fluorescence lymphography was performed by injecting 0.2 mL of ICG into the first web space of the foot. After 4 hours, fluorescence images of lymphatic vessels were obtained and the lymphatic vessels were marked. Three landmarks were designated; the medial malleolus, the medial patellar border, and the groin femoral artery. Straight lines connecting the points were drawn, and the distance between the connected lines and the marked lymphatic vessels was measured in eight points. Results: Fifteen subjects with healthy lower extremities (15 right and 15 left) were included. The average course of the main lymph vessels passed 26.2±18.0 mm dorsally to the medial malleolus, 53.7±35.7 mm medially to the medial patellar border, and 25.5±19.2 mm medially to the three-quarters point of the upper landmark line.Conclusion: The main functioning lymphatic vessel largely follows the great saphenous vein course, passes in front of the medial malleolus, runs over the posterior border of the medial epicondyle at the knee level, and travels anteriorly toward the inguinal lymph nodes.

Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

BackgroundAlmost all liver tumours can be removed laparoscopically, but some difficult tumour locations complicate laparoscopic surgery. Recurrent liver tumours often pose great difficulties to laparoscopic surgery due to adhesions caused by previous operations. Referring to laparoscopic adrenalectomy, a retroperitoneal approach is proposed to remove liver tumours near the adrenal gland, which will provide a new method for liver surgery.Case presentationOur case involves a patient with recurrent hepatocellular carcinoma (HCC) whose last operation was laparoscopic hepatectomy in our department, with a recurrence of HCC 2 years after the first surgery. In this case, based on preoperative CT and MRI, through a retroperitoneal approach, combined with intraoperative ultrasound (IOUS) localization and indocyanine green (ICG) fluorescence navigation, laparoscopic hepatectomy was successfully performed to precisely resect recurrent hepatocellular carcinoma in segment VII. The patient was discharged on the third day after the operation. The AFP decreased to normal levels on the 28th postoperative day.ConclusionsRetroperitoneal hepatectomy has the advantages of less trauma, shorter operation times, fewer complications and faster recovery for hepatic tumours near the adrenal gland. Accurate localization of tumours is needed to ensure accurate resection; therefore, IOUS and ICG fluorescence are very important. Liver parenchyma was severed strictly according to fluorescent labelling during hepatectomy, which prevented the deviation of liver parenchyma from the plane and ensured that the margin of hepatectomy was tumour-free. In order to ensure a radical resection of the tumour, it may be necessary to enter the abdominal cavity.

Indocyanine Green Fluorescence Imaging to Predict Graft Survival After Orthotopic Liver Transplantation: A Pilot Study

The incidence of primary nonfunction (PNF) after liver transplantation (LT) remains a major concern with the increasing use of marginal grafts. Indocyanine green (ICG) fluorescence is an imaging technique used in hepatobiliary surgery and LT. Because few early predictors are available, we aimed to quantify in real time the fluorescence of grafts during LT to predict 3-month survival. After graft revascularization, ICG was intravenously injected, and then the fluorescence of the graft was captured with a near infrared camera and postoperatively quantified. A multiparametric modeling of the parenchymal fluorescence intensity (FI) curve was proposed, and a predictive model of graft survival was tested. Between July 2017 and May 2019, 76 LTs were performed, among which 6 recipients underwent retransplantation. No adverse effects of ICG injection were observed. The parameter a150 (temporal course of FI) was significantly higher in the re-LT group (0.022seconds-1 (0.0011-0.059) versus 0.012seconds-1 (0.0001-0.054); P=0.01). This parameter was the only independent predictive factor of graft survival at 3 months (OR,2.4; 95% CI, 1.05-5.50; P=0.04). The best cutoff for the parameter a150 (0.0155seconds-1 ) predicted the graft survival at 3 months with a sensitivity (Se) of 83.3% and a specificity (Spe) of 78.6% (area under the curve,0.82; 95% CI, 0.67-0.98; P=0.01). Quantitative assessment of intraoperative ICG fluorescence on the graft was feasible to predict graft survival at 3months with a good Se and Spe. Further prospective studies should be undertaken to validate these results over larger cohorts and evaluate the clinical impact of this tool.

Correction to: Intraoperative indocyanine green fluorescence imaging in breast surgery

In the original article published, some of the superscript characters in Table 1 (column p value with superscript references to the footnotes) were incorrectly inserted by the typesetters.

Intraoperative indocyanine green fluorescence imaging in breast surgery

BackgroundSince postoperative complications after reconstructive breast surgery are often related to drastic increases of patient suffering and treatment costs, several devices were developed in order to avoid them. In this respect, the intraoperative fluorescence angiography with indocyanine green (ICG) provides promising results by detecting ischemic skin intraoperatively.MethodsWomen who underwent reconstructive breast surgery at the breast center at Charité between April and December 2017 were included in the analysis. General patient characteristics, medical history, type of surgery, as well as postoperative parameters, complications and patient reported outcomes were compared between patients operated using ICG fluorescence angiography and conventionally operated patients.ResultsAmong 68 patients with breast reconstruction 36 (52.9%) were operated with the ICG angiography device and 32 (47.1%) without. No significant differences regarding patient demographics, medical history, and surgical procedure were found. Wound healing disorders occurred in 11.1% of the ICG group and in 9.4% of the control group. About 11% of both groups developed major complications which required revision surgery. Complication rates and patient reported outcome did not differ significantly. Across both groups, only the risk factor resection weight (≥ 500 g) was significantly associated with wound healing disorders (RR = 6.80; 95%CI 1.93–23.81; p = 0.022).ConclusionThe purchase of a device for intraoperative ICG angiography might not be reasonable for every breast center. Further research in a larger cohort and prospective manner should be done to determine if the addition of ICG to breast reconstructive surgery in the German setting really leads to improved patient care.

Correlation between indocyanine green visualization time in the gastric tube and postoperative endoscopic assessment of the anastomosis after esophageal surgery.

To evaluate the correlation between blood supply speed in the gastric tube (GT), assessed by the intraoperative indocyanine green (ICG) fluorescence method, and postoperative endoscopic assessment (PEA) of the anastomosis or anastomotic leakage (AL). The subjects of this retrospective analysis were 66 consecutive patients who underwent GT reconstruction using ICG fluorescence during esophageal surgery. We measured the ICG visualization time, from ICG injection to visualization at the top of the GT. We performed PEA on 54 patients and classified ulcer formation as involving less than or more than half of the circumference. PEA revealed that nine patients (16.7%) had an anastomotic ulcer involving more than half of the circumference and ten (15.4%) had AL. The ICG visualization time in these patients was significantly delayed compared with that in those with less than half of the circumference involved by ulcer formation (37s vs. 27s; P = 0.015) and without AL (36s vs. 28s; P = 0.045). Multivariate analysis revealed that delay in the ICG visualization time (> 36s) of the pulled-up GT (odds ratio, 6.098; 95% confidence interval, 1.125-33.024; P = 0.036) was an independent risk factor associated with AL. Delay in the ICG visualization time of pulled-up GT was associated with ulcer formation on the anastomosis and AL after esophageal surgery.

The Utility of Indocyanine Green Angiography in the Assessment of Perfusion of Gastric Conduit and Proximal Esophageal Stump Against Visual Assessment in Patients Undergoing Esophagectomy: a Prospective Study.

Post esophagectomy anastomotic leakage is a crucial factor in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complication. This prospective study compares the utility of intraoperative indocyanine green (ICG) fluorescence angiography and visual assessment in assessing the vascularity of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy. Thirteen consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019 were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic-assisted esophagectomy. Reconstruction was done by gastric pull-up via posterior mediastinal route. All patients underwent assessment of perfusion of gastric conduit and proximal esophageal stump by ICG angiography and by visual assessment based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges. Visual assessment revealed the tip of the gastric conduit was dusky and ischemic in 11 patients, pink and well perfused in two. ICG fluorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, adequate in one, overall requiring revision in 12 cases. There was a discrepancy in one patient where visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit's tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and by ICG assessment. The median time to appearance of blush from the time of injection of dye was 15s (10 to 23s). In all the cases, the pattern of blush was simultaneous, with the concurrent appearance of ICG blush in the gastric conduit and gastro-epiploic arcade. No anastomotic leaks were noted. Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in randomized trials.

Intraoperative Assessment of DIEP Flap Breast Reconstruction Using Indocyanine Green Angiography: Reduction of Fat Necrosis, Resection Volumes, and Postoperative Surveillance.

This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure. Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler diameter (OR, 0.031 per 1-mm increase; p = 0.012). The 84.9-g higher weight of resected tissue before inset without indocyanine green angiography versus the weight of the tissue resected with indocyanine green angiography was statistically significant (p = 0.01). Per single incident of fat necrosis, our cohort underwent an additional 0.69 revision procedures, 1.22 imaging studies, 0.77 biopsies, and 1.7 additional oncologic office visits. Intraoperative indocyanine green fluorescence angiography decreases the odds of fat necrosis, saves volume when flap trimming at inset, and can significantly reduce the postoperative surveillance burden in DIEP-based breast reconstruction. Therapeutic, III.