Indocyanine Green Fluorescence Angiography During Laparoscopic Bariatric Surgery: A Pilot Study

Abstract

AimsIndocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate.MethodsThirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2–58.7 years) and preoperative median body mass index of 42.6 kg/m2 (CI, 95% 36 to 49.3 kg/m2) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures.ResultsFom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case.ConclusionsICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions.

Fluorescence use in minimally invasive metabolic and bariatric surgery — a systematic review of the literature

“…One study reported the simultaneous use of ICG and methylene blue [ 27 ]. Fluorescence was used in 280 (66.03%) patients for LSG [ 18 – 22 , 24 , 28 , 30 ], 137 (32.32%) for RYGB [ 22 , 25 , 27 – 30 ], 5 (1.18%) for revisional surgery [ 22 , 23 ], 1 (0.24%) for the removal of an adjustable gastric band (AGB) [ 30 ] and 1 (0.24%) for LSG combined with Rossetti fundoplication [ 26 ]. One hundred fifty-four (36.32%) surgeries were performed with the assistance of robotic technology [ 27 , 28 ].…”

Assessment of gastric pouch blood supply with indocyanine green fluorescence in conversional and revisional bariatric surgery: a prospective comparative study

“…Severe side effects due to the administration of ICG are mostly related to allergic reactions and are extremely rare 16 , 18 . In our series, no ICG-related complications were recorded, and also the intraoperative time dedicated to the test was low (a few minutes).…”

“…We also compared our prospective series of patients to a retrospective control group with similar characteristics and no difference in postoperative complications was noted. Recently, Balla et al 16 published a series of 13 patients who underwent either primary or conversional bariatric surgery. The authors scored the ICG-tested vascular supply and found that in two out of four conversional cases (from SG to GB) a change of the surgical strategy was deemed necessary.…”

“…However, the use of indocyanine green in bariatric surgery has never been considered mandatory or necessary like in colorectal surgery, as the blood supply of the stomach is generally adequate 10 , 11 , 15 . Few studies have assessed the usefulness of ICG fluorescence in primary or reoperative bariatric surgery 11 , 16 – 18 .…”

Intraoperative fluorescence imaging using indocyanine green to assess the lymphatic drainage of a small bowel adenocarcinoma

“…This ease of implementation has prompted wider adoption of ICG fluorescence in gastrointestinal surgery, most commonly to assess perfusion of gastrointestinal anastomoses, which may reduce the incidence of anastomotic leak 2 . The safety and efficacy of ICG fluorescence has led to additional uses intraoperatively, including ureter identification, visualization of the biliary tract during cholecystectomy, detecting ischaemic leak in bariatric surgery, visualization of tumours that are challenging to identify laparoscopically, and endoscopic tattooing of lesions 1,3,4 . Here, we present a case in which a novel application of intraoperative ICG fluorescence imaging is used to identify the lymphatic drainage basin of a primary small bowel adenocarcinoma where nodal anatomy is distorted due to the presence of an ileoanal J‐pouch.…”