Intraoperative fluorescence angiography with indocyanine green: retrospective evaluation and detailed analysis of our single-center 5-year experience focused on colorectal surgery

Abstract

Objectives: Assessing bowel perfusion with indocyanine green fluorescence angiography (ICG-FA) shows positive effects on anastomotic healing in colorectal surgery.

Methods: A retrospective evaluation of 296 colorectal resections where we performed ICG-FA was undertaken from January 2014 until December 2018. Perfusion of the bowel ends measured with ICG-FA was compared to the visual assessment before and after performing the anastomosis. According to the observations, the operative strategy was confirmed or changed. Sixty-seven low anterior rectal resections (LARs) and 76 right hemicolectomies were evaluated statistically, as ICG-FA was logistically not available for every patient in our service and thus a control group for comparison resulted.

Results: The operative strategy based on the ICG-FA results was changed in 48 patients (16.2%), from which only one developed an anastomotic leakage (AL) (2.1%). The overall AL rate was calculated as 5.4%. Within the 67 patients with LAR, the strategy was changed in 11 patients (16.4%). No leakage was seen in those. In total three AL happened (4.5%), which was three times lower than the AL rate of 13.6% in the control group but statistically not significant. From the 76 right hemicolectomies a strategy change was undertaken in 10 patients (13.2%), from which only one developed an AL. This was the only AL reported in the whole group (1.3%), which was six times lower than the leakage rate of the control group (8.1%). This difference was statistically significant (p=0.032).

Conclusions: Based on the positive impact by ICG-FA on the AL rate, we established the ICG-FA into our clinical routine. Although randomized studies are still missing, ICG-FA can raise patient safety, with only about 10 min longer operating time and almost no additional risk for the patients.

Keywords: anastomotic leakage; colorectal surgery; fluorescence angiography; fluorescence imaging; indocyanine green; perfusion.

Figure 1:

ICG-FA before dissection of the descending colon. Instrument pointing at the site of dissection in the well perfused area (orange).

Figure 2:

Hypogastric plexus, left and right branches of the hypogastric nerve at the promontorium (red arrows).