ICG fluorescence imaging in colorectal surgery: a snapshot from the ICRAL study group

Abstract

Background Fluorescence-guided visualization is a recently proposed technology in colorectal surgery. Possible uses include evaluating perfusion, navigating lymph nodes and searching for hepatic metastases and peritoneal spread. Despite the absence of high-level evidence, this technique has gained considerable popularity among colorectal surgeons due to its significant reliability, safety, ease of use and relatively low cost. However, the actual use of this technique in daily clinical practice has not been reported to date. Methods This survey was conducted on April 2020 among 44 centers dealing with colorectal diseases and participating in the Italian ColoRectal Anastomotic Leakage (iCral) study group. Surgeons were approximately equally divided based on geographical criteria from multiple Italian regions, with a large proportion based in public (89.1%) and nonacademic (75.7%) centers. They were invited to answer an online survey to snapshot their current behaviors regarding the use of fluorescence-guided visualization in colorectal surgery. Questions regarding technological availability, indications and techniques, personal approaches and feelings were collected in a 23-item questionnaire. Results Questionnaire replies were received from 37 institutions and partially answered by 8, as this latter group of centers do not implement fluorescence technology (21.6%). Out of the remaining 29 centers (78,4%), fluorescence is utilized in all laparoscopic colorectal resections by 72.4% of surgeons and only for selected cases by the remaining 27.6%, while 62.1% of respondents do not use fluorescence in open surgery (unless the perfusion is macroscopically uncertain with the naked eye, in which case 41.4% of them do). The survey also suggests that there is no agreement on dilution, dosing and timing, as many different practices are adopted based on personal judgment. Only approximately half of the surgeons reported a reduced leak rate with fluorescence perfusion assessment, but 65.5% of them strongly believe that this technique will become a minimum requirement for colorectal surgery in the future. Conclusion The survey confirms that fluorescence is becoming a widely used technique in colorectal surgery. However, both the indications and methods still vary considerably; furthermore, the surgeons' perceptions of the results are insufficient to consider this technology essential. This survey emphasizes the need for further research to reach recommendations based on solid scientific evidence.

Characterization of Near-Infrared Imaging and Indocyanine-Green Use Amongst General Surgeons: A Survey of 263 General Surgeons

“… 32 , 33 Uptake by colorectal surgeons in our study is consistent with rates recently reported by Italian surgeons. 34 In contrast rates for ICG use amongst bariatric, foregut, and thoracic surgeons has not previously been reported, yet the increased use amongst those specialties is not surprising given the evolving literature in the respective disciplines. More frequent use amongst foregut, thoracic, and bariatric surgeons is in keeping with ease of NIRFI integration into their surgical techniques due to a high volume of laparoscopic procedures enabling routine access to NIRFI equipment.…”

The current status and future prospects for molecular imaging-guided precision surgery

“…The success stories in the field of image-guided surgery are based on technologies that maximally align with innovations made in other fields. For example, initial work on fluorescence laparoscopy presented in prostate cancer surgery [ 195 ] was later transferred to breast surgery [ 196 ] and the technique is now also implemented during i.e., laparoscopic colorectal surgery [ 94 , 197 ]. Such knowledge sharing can be considered highly valuable as it helps boost innovation across disciplines.…”

Safety and Efficacy of Indocyanine Green in Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis of 11,047 Patients

“…It allows intraoperative real-time assessment of the blood supply to the stumps of the large intestine after resection and to the intestine after anastomosis [ 2 ]. Good blood supply to the anastomosis is crucial for proper healing and preventing intestinal anastomotic leak [ 3 ].…”