Use Of Indocyanine Green Fluorescence Angiography Research Articles

Indocyanine green fluorescence angiography in pediatric intestinal resections: A first prospective mixed methods clinical trial

BackgroundThe aim of this study was to establish the feasibility and safety of the use of indocyanine green technology during pediatric intestinal resections. While indocyanine green fluorescence angiography (ICG-FA) has been advocated as an imaging technique to assess bowel perfusion in adults, few studies have evaluated this technology in a pediatric context. MethodsA prospective clinical trial was conducted. Patients 16 years old or younger undergoing a surgery potentially requiring an intestinal resection were eligible. Patients received a standardized intravenous injection of indocyanine green and intestinal perfusion was evaluated. The study endpoints included safety, impact on bowel resection and feasibility and acceptance of ICG-FA in this population. ResultsFrom May 2020 to March 2021, 30 consecutive patients were included in this trial. Final analysis was done on 28 patients with a median age of 15.00 [6.36,85.00] weeks and weight of 5.58 [3.64,11.70] kg at surgery. Adequate fluorescence was achieved in less than one minute for all cases with an average dose of 0.14 mg/kg. No adverse event related to indocyanine green occurred. ICG-FA versus standard assessment of potential resection sites differed in 62% (95% IC 0.41–0.82) of our cases. Qualitative analysis demonstrated that 95% of the surgical team agreed that ICG-FA was safe. ConclusionsThe use of ICG-FA is feasible and safe for pediatric intestinal resections. Introduction of ICG-FA was simple and acceptance rates were high within the surgical team. This fluorescence imaging may be a valuable imaging technology for intestinal resections in pediatric surgery.

P-151 ROLE OF INDOCYANINE GREEN TO MITIGATE WOUND COMPLICATIONS IN ANTERIOR COMPONENT SEPARATION TECHNIQUE FOR VENTRAL HERNIA REPAIR- OUR EARLY EXPERIENCE

Abstract Aim The subjective ease of anterior component separation technique (ACST) has made it a widely used surgical option amongst budding surgeons for ventral hernia repairs (VHR). However, surgical site occurrences (SSO) like flap necrosis due to compromised perfusion have frequently been reported. This study aims to evaluate the impact of adoption of indocyanine green-fluorescence angiography (ICG-FA) to map soft tissue perfusion on wound-related complications following open ACST in VHR. Material & Methods We performed a retrospective review of patients who underwent VHR with open ACST at a single centre between March 2018 and July 2020. The study comprised of consecutive cases of ACST with onlay meshplasty done before (March 2018–April 2019, n=24) and after (May 2019 to July 2020, n=19) implementation of ICG-FA for intra-operative perfusion mapping of subcutaneous tissue and skin. Results The pre-ICG group and post-ICG group were similar in terms of baseline patient demographics and peri-operative details. The rate of SSO was higher in the pre-ICG group, but this result was not statistically significant (46% vs. 26%; p value 0.189). Skin necrosis, however, was observed in significantly less number of patients in the post-ICG cohort (29% vs. 5%; p value 0.045). No mesh infection was observed in either group. Conclusion This study demonstrates the effectiveness of perfusion mapping by the use of ICG-FA to determine potential areas of decreased perfusion and thereby minimize wound complications.

Indocyanine green fluorescence in robot-assisted minimally invasive esophagectomy with intrathoracic anastomosis: a prospective study

Indocyanine green fluorescence angiography (ICG-FA) allows for real-time intraoperative assessment of the perfusion of the gastric conduit during esophagectomy. The aim of this study was to investigate the effect of the implementation of ICG-FA during robot-assisted minimally invasive esophagectomy (RAMIE) with an intrathoracic anastomosis. In this prospective cohort study, a standardized protocol for ICG-FA was implemented in a high-volume center in December 2018. All consecutive patients who underwent RAMIE with an intrathoracic anastomosis were included. The primary outcome was whether the initial chosen site for the anastomosis on the gastric conduit was changed based on ICG-FA findings. In addition, ICG-FA was quantified based on the procedural videos. Out of the 63 included patients, the planned location of the anastomosis was changed in 9 (14%) patients, based on ICG-FA. The median time to maximum intensity at the base of the gastric conduit was shorter (25 s; range 13–49) compared to tip (34 s; range 12–83). In patients with anastomotic leakage, the median time to reach the FImax at the tip was 56 s (range 30–83) compared to 34 s (range 12–66) in patients without anastomotic leakage (p = 0.320). The use of ICG-FA resulted in an adaptation of the anastomotic site in nine (14%) patients during RAMIE with intrathoracic anastomosis. The quantification of ICG-FA showed that the gastric conduit reaches it maximum intensity in a base-to-tip direction. Perfusion of the entire gastric conduit was worse for patients with anastomotic leakage, although not statistically different.

The utilization of indocyanine green fluorescence angiography for anastomotic perfusion assessment following bowel resection for gynecologic malignancies: A pan-Canadian survey (545)

Objectives: Bowel resection is an important component of surgical management of women with advanced gynecologic malignancies. Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that has been shown to effectively evaluate perfusion of large and small bowel anastomoses. The objective of this study was to capture national practice patterns, characterize facilitators and barriers to ICG-FA utilization for bowel perfusion assessment, and identify opportunities for further education across Canada. Methods: A needs assessment survey was developed with a focus group of key stakeholders in the field, as well as a methodologist, and piloted in advance to distribution. The survey captured basic sociodemographics, work history, facilitators and barriers to use of ICG-FA for bowel perfusion assessment, and modalities for further education (e.g., peer-reviewed article, surgical video, national/ international conference, local grand rounds, and invited experts for practical training). On July 1, 2021, the survey was distributed to 115 gynecologic oncologists registered through the Society of Gynecologic Oncology of Canada. Responses were collected until September 1, 2021. Results: The response rate was 31% (n=37), with respondents from all Canadian provinces. Approximately three-quarters (78%) of respondents identified as women, and the majority (60%) have been practicing gynecologic oncology for less than ten years. Of the respondents, 81% (n=30) performed bowel resection, and 67% (n=20) used ICG-FA for anastomotic perfusion assessment after bowel surgery. The three most reported barriers to integrating ICG-FA into routine clinical practice were the lack of training (30%), knowledge (27%), and equipment (27%). Surgical videos were the highest-ranked educational modality, followed by national/international conferences and peer- reviewed articles. Conclusions: ICG-FA for bowel perfusion assessment is a valuable tool that can be used with other risk-assessment strategies to guide operative decision-making in gynecologic oncology. However, further training across multiple educational modalities is needed to build knowledge among the Canadian gynecologic oncologic community, with surgical videos serving as the preferred educational modality. Additionally, more funding for necessary equipment will facilitate the uptake of this tool. This represents a national practice improvement opportunity. Objectives: Bowel resection is an important component of surgical management of women with advanced gynecologic malignancies. Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that has been shown to effectively evaluate perfusion of large and small bowel anastomoses. The objective of this study was to capture national practice patterns, characterize facilitators and barriers to ICG-FA utilization for bowel perfusion assessment, and identify opportunities for further education across Canada. Methods: A needs assessment survey was developed with a focus group of key stakeholders in the field, as well as a methodologist, and piloted in advance to distribution. The survey captured basic sociodemographics, work history, facilitators and barriers to use of ICG-FA for bowel perfusion assessment, and modalities for further education (e.g., peer-reviewed article, surgical video, national/ international conference, local grand rounds, and invited experts for practical training). On July 1, 2021, the survey was distributed to 115 gynecologic oncologists registered through the Society of Gynecologic Oncology of Canada. Responses were collected until September 1, 2021. Results: The response rate was 31% (n=37), with respondents from all Canadian provinces. Approximately three-quarters (78%) of respondents identified as women, and the majority (60%) have been practicing gynecologic oncology for less than ten years. Of the respondents, 81% (n=30) performed bowel resection, and 67% (n=20) used ICG-FA for anastomotic perfusion assessment after bowel surgery. The three most reported barriers to integrating ICG-FA into routine clinical practice were the lack of training (30%), knowledge (27%), and equipment (27%). Surgical videos were the highest-ranked educational modality, followed by national/international conferences and peer- reviewed articles. Conclusions: ICG-FA for bowel perfusion assessment is a valuable tool that can be used with other risk-assessment strategies to guide operative decision-making in gynecologic oncology. However, further training across multiple educational modalities is needed to build knowledge among the Canadian gynecologic oncologic community, with surgical videos serving as the preferred educational modality. Additionally, more funding for necessary equipment will facilitate the uptake of this tool. This represents a national practice improvement opportunity.

Efficacy of the Intraoperative Use of Indocyanine-Green Fluorescence Angiography in Laparoscopic Rectal Resections

Background: In traditional laparoscopic colorectal cancer surgery, the surgeon’s method assess intestinal stumps blood supply is subject to certain subjectivity and blindness. Indocyanine green (ICG) real-time blood perfusion fluorescence angiography in laparoscopic radical resection of rectal cancer has great potential clinical value and can visually judge intestinal tract blood supply to improve the surgery safety, reduce postoperative complications, and ensure the recovery of patients after surgery. Objective: To explore the efficacy of the intraoperative use of indocyanine-green fluorescence angiography in laparoscopic rectal resections in patients with rectal cancer. Methods: In the present study, 109 rectal cancer patients were included and assigned to different surgical groups [ICG and control groups] for analysis. Statistical analysis was carried out for various common postoperative complications in the two groups. Finally, the patients in the ICG fluorescence imaging group had a timely adjustment of the proximal resection of the intestinal tube before the proximal bowel of the lesion was cut off when the intestinal blood supply was insufficiently assessed by fluorescence imaging. Two subgroups, the adjustment and the non-adjustment groups, were analyzed. Results: Compared with the control group, the postoperative anal ventilation time in the ICG group was shorter than that in the control group (P 0.05). In addition, the postoperative complications were lower than those in the control group, and the differences were statistically significant (P 0.05). However, the distance between the tumor from the anal verge in the adjustment group was smaller than that in the non-adjustment group, and the difference was statistically significant (P 0.01). Conclusion: Compared with conventional laparoscopic radical resection of rectal cancer, ICG real-time indocyanine green fluore- scence angiography was safe and feasible. This technique is a promising intraoperative tool for the assessment of bowel perfusion especially suitable for patients with lower rectal cancer.

Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy.

Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260mL [95-463] versus 75mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.

Indocyanine green fluorescence angiography prevents anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis.

The role of intraoperative use of indocyanine green (ICG) fluorescence angiography (ICGFA) to prevent anastomotic leakage (AL) in rectal cancer surgery remains controversial. The systematic review for studies evaluating ICGFA in patients undergoing rectal cancer surgery in PubMed, Embase, Web of Science, and the Cochrane Library was performed up to April 30, 2020. The primary outcome was the incidence of AL. The analysis was performed using RevMan v5.3 and Stata v12.0 software. Eighteen studies comprising 4038 patients were included. In the present meta-analysis, intraoperative use of ICGFA markedly reduced AL rate (OR = 0.33; 95% CI: 0.24-0.45; P< 0.0001; I2= 0%) in rectal cancer surgery, which was still significant in surgeries limited to symptomatic AL (OR = 0.44; 95% CI: 0.31-0.64; P< 0.0001; I2= 22%). This intervention was also associated with shorter postoperative stays (MD = - 1.27; 95% CI: - 2.42 to - 0.13; P= 0.04; I2= 60%). However, reoperation rate (OR = 0.61; 95% CI: 0.34-1.10; P= 0.10; I2= 6%), ileus rate (OR = 1.30; 95% CI: 0.60-2.82; P= 0.51; I2= 56%), and surgical site infection rate (OR = 1.40; 95% CI: 0.62-3.20; P= 0.42; I2= 0%) were not significantly different between the two groups. The use of ICGFA was associated with a lower AL rate after rectal cancer resection. However, more multi-center RCTs with large sample size are required to further verify the value of ICGFA in rectal cancer surgery.

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.

Indocyanine green angiography for preventing postoperative mastectomy skin flap necrosis in immediate breast reconstruction.

Indocyanine green angiography for preventing postoperative mastectomy skin flap necrosis in immediate breast reconstruction.

The use of indocyanine green fluorescence angiography for colorectal anastomoses in cytoreductive surgery for ovarian carcinoma

Objective: Real-time intraoperative assessment of anastomotic perfusion with indocyanine green fluorescence angiography (ICG-FA) is a recent technique that has been associated with a lower risk of anastomotic leak in the general surgery literature. No studies to date have evaluated its use in patients with gynecologic malignancies. Our objective was to describe feasibility and safety of the use of ICG-FA by reporting our initial experience incorporating this tool into routine surgical practice.

The use of indocyanine green fluorescence angiography to assess perfusion of chronic wounds undergoing hyperbaric oxygen therapy

The purpose of this study is to determine the utility of using indocyanine green fluorescence angiography (IGFA) in assessing perfusion of chronic wounds after hyperbaric oxygen (HBO2) therapy. From May 2016 to January 2018, 26 patients underwent both HBO2 and IGFA. A near-infrared charge-coupled camera measured the flow of intravenous indocyanine green into the wound. IGFA was done pre-HBO2, after approximately 10 HBO2 sessions, and upon completion of HBO2. The ingress rate at baseline, mid-therapy and post-HBO2 values were compared using descriptive statistics. A total of 26 chronic wounds were identified. Baseline median ingress rate was 0.90 units/second (IQR: 0.28 to 6.10). Median ingress rate after approximately of 10 HBO2 sessions was 2.45 units/sec (IQR: 0.48 to 6.35). Six of 11 patients, however, exhibited a decrease in ingress rate from baseline to mid-therapy. Finally, median ingress rate post-HBO2 was 3.70 units/second (IQR: 0.30 to 9.90). Median increase in ingress and rate from baseline to mid-HBO2 treatment 0.30 units/second (IQR: -0.25 to 3.10) and from mid- to post-HBO2 was -0.40 units/second (IQR: -1.50 to 2.60). This preliminary study shows capability of IGFA to detect changes in blood flow to wounds following HBO2 therapy. Results support the use of IGFA to evaluate the changes in perfusion of patients undergoing HBO2 for chronic wounds. A larger sample size may help clarify the benefit of IGFA to predict potential for wound healing.

Intraoperative use of dynamic infrared thermography and indocyanine green fluorescence video angiography to predict partial skin flap loss

Inadequate perfusion is the most common cause of partial flap loss in reconstructive surgery. Intraoperative monitoring of flap perfusion may prevent such loss. This study compared indocyanine green fluorescence angiography (ICG-FA) and dynamic infrared thermography (DIRT) in their ability to predict intraoperatively the percentage of flap survival in a caudally based McFarlane flap in 10 male Wistar rats. The intraoperative images of both techniques were subjectively and objectively analysed. The percentage of flap survival, as judged from the digital colour photographs 7 days post-operatively, was 69 ± 3%. Objective analysis of flap survival based on intraoperative DIRT and ICG-FA (74 vs 63%, respectively) correlated quite well with the subjective measurements (75 ± 2 vs 59 ± 4%, respectively). However, intraoperative ICG-FA images underestimated flap survival by 6–10%, while intraoperative DIRT images overestimated the flap survival by 5–6%. The authors conclude that intraoperative use of ICG-FA and DIRT can provide valuable information on areas with inadequate perfusion as long as their limitations are respected.