Impact of intraoperative indocyanine green fluorescence angiography on anastomotic leakage after laparoscopic sphincter-sparing surgery for malignant rectal tumors

Abstract

Whether indocyanine green fluorescence angiography (ICG-FA) during rectal surgery is effective in reducing anastomotic leakage remains unclear. This study aimed to investigate the effect of intraoperative ICG-FA on anastomotic leakage after sphincter-sparing surgery for malignant rectal tumors. MethodsThis was a retrospective, single-center cohort study conducted on 852 consecutive patients who underwent laparoscopic sphincter-sparing surgery from January 2007 to June 2017 at our institution. The incidence of anastomotic leakage was compared between patients who underwent ICG-FA to determine the proximal resection margin and those in whom this technique was not performed, using logistic regression analysis, including propensity score. ResultsA total of eight patients were excluded (one patient with previous low anterior resection and seven patients who underwent simultaneous resection for other primary cancers), resulting in 844 patients being analyzed. Before propensity score matching, 141 patients (16.7%) who underwent ICG-FA were compared with 703 patients (83.3%) in whom ICG-FA was not performed. The incidence of anastomotic leakage was 2.8% (4/141) in the ICG-FA group and 12.4% (87/703) in the control group (p = 0.001).After propensity score matching (n = 420), the patient characteristics between the two groups were well 4 balanced, and the incidence of anastomotic leakage was 2.8% (4/141) in the ICG-FA group and 13.6% (38/279) in the control group (p = 0.001). Logistic regression analyses using propensity score showed that patients who underwent ICG-FA had significantly lower odds of anastomotic leakage. ConclusionIntraoperative ICG-FA is a promising method to reduce anastomotic leakage after laparoscopic rectal surgery.

Indocyanine Green-Enhanced Colorectal Surgery—between Being Superfluous and Being a Game-Changer

“…Our research identified 71 articles related to the use of ICG in vascular assessment of anastomoses, but only 23 papers remained eligible for review after a PRISMA evaluation [ 13 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. The ensuing comments and critical reflections are based on data from 3146 patients enrolled in 23 non-randomized studies on the use of ICG-enhanced NIR fluorescence for vascular evaluation of anastomoses in colorectal surgery involving open, laparoscopic, or robotic procedures ( Table 1 ).…”

“…Some authors included all colorectal surgeries [ 13 , 17 , 25 , 29 , 32 , 34 , 35 , 36 ] for both benign and malign pathologies, as well as for all locations, while others focused on the most vulnerable colorectal segments with regard to blood supply, namely, the left colon and low colorectal anastomosis [ 19 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 30 , 31 , 32 , 33 , 37 , 38 ]. In 13 of the studies [ 12 , 15 , 17 , 18 , 19 , 21 , 22 , 23 , 24 , 29 , 30 , 33 , 34 ], only the group of patients receiving ICG was described, while in 10 studies [ 16 , 20 , 25 , 26 , 27 , 28 , 31 , 32 , 35 , 36 ], comparative lots of ICG and non-ICG patients were analyzed to evaluate the final outcome. In many cases, however, the control lots w...…”

“…When only left colo-rectal surgery was evaluated, the average rate of AL in ICG group was of 3.75% (0–8.8%), as opposed to an average of 11.45% (5.4–14.7%) in the non-ICG group. When a control group was used, a significant lower number of AL when ICG was used to assess the blood supply at the anastomotic level was encountered in all studies [ 23 , 24 , 26 , 27 , 28 , 30 , 33 , 37 ]. In these groups, anatomically predisposed to high risk of vascular insufficiency, the incidence of AL after evaluation by ICG dropped below 6%, compared to the estimate rate of 10–15% in the current literature.…”

Risk factors for anastomotic leakage after laparoscopic low anterior resection: A single‐center retrospective study

“…Regarding the relationship between blood loss and AL, Hui Qu 36 conducted a meta‐analysis of seven retrospective and seven prospective trials evaluating risk factors for AL in patients with laparoscopic low anterior resection and reported that intraoperative transfusions/blood loss (>100 mL) was one of the risk factors for AL. Blood supply is necessary for wound healing at the anastomotic site, and the use of indocyanine green fluorescence imaging intraoperatively is effective in evaluating blood flow at the anastomotic site and also in reducing AL 37‐39 . Although the estimated blood loss in laparoscopic surgery is smaller than that in laparotomy, the relationship between blood supply at the anastomosis and blood loss is unclear.…”

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

“…Several comparative retrospective and prospective studies investigated the relationship between the use of ICG and the 30-d AL rate as the primary outcome[ 31 , 33 , 38 - 40 ]. They showed a statistically significant correlation between ICG FA and reduction in the risk of AL associated with the modification of the proximal section line.…”