Preliminary Use of Indocyanine Green Fluorescence Angiography and Value in Predicting the Vascular Supply of Tissues Needed to Perform Cloacal, Anorectal Malformation, and Hirschsprung Reconstructions

Abstract

Introduction Reconstructive techniques for cloaca, anorectal malformations (ARM), and Hirschsprung disease (HD) may require intestinal flaps on vascular pedicles for vaginal reconstruction and/or colonic pull-throughs. Visual assessment of tissue perfusion is typically the only modality used. We investigated the utility of intraoperative indocyanine green fluorescence angiography (ICG-FA) and hypothesized that it would be more accurate than the surgeon's eye. Materials and Methods Thirteen consecutive patients undergoing cloacal reconstruction (9), HD (3), and ARM repair (1) underwent ICG-FA laser SPY imaging to assess colonic, rectal, vaginal, and neovaginal tissue perfusion following intraoperative visual clinical assessment. Operative findings were correlated with healing at 6 weeks, 3 months, and 1 year postoperatively. Results ICG-FA resulted in a change in the operative plan in 4 of the 13 (31%) cases. In three cases, ICG-FA resulted in the distal bowel being transected at a level (>10 cm) higher than originally planned, and in one case the distal bowel was discarded, and the colostomy used for pull-through. Conclusion ICG-FA correctly identified patients who might have developed a complication from poor tissue perfusion. Employing this technology to assess rectal or neovaginal pull-throughs in cloacal reconstructions, complex HD, and ARM cases may be a valuable technology.

The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis

“…A total of 937 articles were retrieved through the initial database search, and 93 were additionally identified in January 2021. One study was included after hand-searching references ( 53 ). Sixty-four articles, including 664 pediatric patients, from 2003 to 2020 met the inclusion criteria for narrative synthesis in our systematic review.…”

“…In pediatric surgery and pediatric urology, ICG-FA indications included cholecystectomy ( n = 8) ( 13 , 14 , 22 , 23 , 26 , 28 , 31 , 55 ), primary and metastatic hepatoblastoma ( n = 6) ( 16 , 44 , 48 , 59 , 64 , 70 ), varicocelectomy ( n = 5) ( 22 , 24 – 26 , 31 ), nephrectomy ( n = 5) ( 22 , 25 , 26 , 28 , 32 ), chylous leaks and ascites ( n = 4) ( 15 , 47 , 51 , 56 ), colorectal procedures including cloacal, anorectal malformation, and Hirschsprung reconstructions, intestinal resection for volvulus, as well as stoma closure ( n = 4) ( 37 , 53 , 55 , 69 ), hepatocellular carcinoma ( n = 1) ( 18 ), abdominal mass excision ( n = 1) ( 22 ), and tracheoesophageal fistula ( n = 1) ( 58 ). Pediatric neurosurgeons used ICG-FA in patients with Moyamoya disease to evaluate the anatomy and confirm patency of their surgical anastomoses ( n = 4) ( 9 , 35 , 36 , 62 ).…”

“…ICG-FA can also confirm vascular anastomosis patency in children ( 22 , 23 , 74 ). In pediatric colorectal surgery, Rentea et al ( 53 ) reported a change in the operative plan with ICG use in 4/12 (33%) patients undergoing surgery for anorectal malformations, cloaca, and Hirschsprung disease. In these four cases, the vascular supply of tissues seemed well-perfused on macroscopic inspection, but the use of ICG-FA demonstrated a poorly perfused proximal bowel which led to additional surgical steps including further resection ( n = 2), splenic flexure mobilization ( n = 1), and colostomy ( n = 1).…”

Clinical Application of Indocyanine Green Fluorescence Imaging in the Resection of Hepatoblastoma: A Single Institution's Experiences

“…ICG fluorescence imaging is widely used in surgical navigation, but its clinical application in pediatric surgery is still in its infancy (15). The use of preoperatively injected intravenous ICG and nearinfrared imaging equipment has emerged as a novel therapy in cases of HB and metastatic resections (16)(17)(18). As is well known, ICG is retained in the tumor tissue much longer than in the normal liver parenchyma (19).…”

Fluorescence imaging in pediatric surgery: State-of-the-art and future perspectives

“…Being surgical repairs of AnoRectal Malformations (ARM) and Hirschsprung Disease (HD) based on pedicled intestinal grafts and pull-throughs, the real-time assessment of the vascular flow seems to be a promising tool to prevent postoperative strictures and anastomotic leakages. In this respect, Rentea et al(17) investigated the role of ICG fluorescence angiography to assess rectal and neovaginal pull-throughs in cloacal reconstructions (n=9), complex ARM (n=1) and HD (n=3) repairs. It significantly impacted the intraoperative decision-making process in a third of patients, including the refashioning of an intestinal anastomosis (n=1), choosing a more proximal resection margin (n=2) or completely discharging a portion of bowel (n=1).…”