Indocyanine green fluorescence angiography: a new ERAS item

Abstract

ERAS protocol and indocyanine green fluorescence angiography (ICG-FA) represent the new surgical revolution minimizing complications and shortening recovery time in colorectal surgery. As of today, no studies have been published in the literature evaluating the impact of the ICG-FA in the ERAS protocol for the patients suitable for colorectal surgery. The aim of our study was to assess whether the systematic evaluation of intestinal perfusion by ICG-FA could improve patients outcomes when managed with ERAS perioperative protocol, thus reducing surgical complication rate. This is a retrospective case-control study. From March 2014 to April 2017, 182 patients underwent laparoscopic colorectal surgery for benign and malignant diseases. All the patients were enrolled in ERAS protocol. Two groups were created: Group A comprehended 107 patients managed within the ERAS pathway only and Group B comprehended 75 patients managed as well as with ERAS pathway plus the intraoperative assessment of intestinal perfusion with ICG-FA. Two board-certified laparoscopic colorectal surgeons jointly performed all procedures. Six (5.6%) clinically relevant anastomotic leakages (AL) occurred in Group A, while there was none in Group B, demonstrating that ICG-FA integrated in the ERAS protocol can lead to a statistically significant reduction of the AL. Mean operative time between the two groups was not statistically significant. In five cases (6.6%), the demarcation line set by the fluorescence made the surgeon change the resection line previously marked. The prevalence of all other complications did not differ statistically between the two groups. Our study confirms that combination between ICG and ERAS protocol is feasible and safe and reduces the anastomotic leakage, possibly leading to consider ICG-FA as a new ERAS item.

Intraoperative testing of colorectal anastomosis and the incidence of anastomotic leak

“…[ 39 ] Also, only IOE can identify some other—rare, but threatening intraoperative complications as intensive anastomotic suture-line bleeding or others. [ 34 ] Therefore, technically more challenging and more expensive IOE may be a better alternative to air-leak and methylene blue tests.…”

Quantifying tissue perfusion after peripheral endovascular procedures: Novel tissue perfusion endpoints to improve outcomes

“…Indocyanine green (ICG) fluorescence angiography was initially used in retinal vessel imaging[ 83 ] and subsequently in the evaluation of tissue perfusion in various medical fields[ 84 , 85 ]. Following intravenous injection of the fluorescent ICG dye, the latter is activated by the use of near-infrared laser (approximately 780 nm)[ 84 ].…”

Intraoperative fluorescence imaging during complex urologic pelvic surgery

“…Thus, further information may be attained regarding anatomy, perfusion, or lymphatic drainage. 7 Standard dosing up to 5 mg/kg intravenously is considered non-toxic with iodine allergy as the only major contraindication. It features a favorable adverse effect profile, with a low complication rate of 0.34% of nausea, vomiting and rarely shock.…”

“…23 In colorectal surgery, feasibility and safety of ICG implementation within ERAS has been explored with demonstration of significant reduction in anastomotic leak while maintaining similar operative times. 7 Thus, ICG has a potential role to play within expedited perioperative protocols for Urologic pelvic extirpative surgery. Not only is fluorescence technology safe and easy to use, but it serves as a means to maximize oncologic outcome while reducing comorbidity in the patient requiring pelvic surgical resection.…”