The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery

doi:10.1016/j.amjsurg.2012.11.005

The American Journal of Surgery

Volume 205, Issue 3, March 2013, Pages 349-353

https://doi.org/10.1016/j.amjsurg.2012.11.005 Get rights and content

Abstract

Background

Esophagectomy with reconstruction using a gastric conduit is associated with a relatively high rate of anastomotic leakage. We used indocyanine green tissue angiography to evaluate the gastric conduit intraoperatively before gastroesophageal anastomosis to identify ischemia.

Methods

We performed an institutional review board–approved retrospective review of all esophagectomies performed from 2010 to the beginning of 2011. Patient histories and perioperative outcomes were reviewed retrospectively. Postoperative morbidity and 30-day mortality were determined.

Results

Eleven patients had an esophagectomy performed using this technology. All had adequate perfusion on gross examination. All but 1 had good perfusion with tissue angiography, and there were 2 anastomotic leakages leaks including this patient. There were no mortalities at 30 days.

Conclusions

We report preliminary results using this imaging system in esophageal reconstructive surgery. Larger randomized controlled studies are needed to determine if surgical outcomes can be improved using this technology.

Section snippets

Methods

We performed an institutional review board–approved retrospective review of all of the esophagectomies performed since we began using the SPY Imaging System, which was from 2010 to early 2011. The preoperative workup, intraoperative findings, and the postoperative course were reviewed. Operative notes and SPY camera images were reviewed to determine the surgeon's clinical assessment of the perfusion to the conduit before formation of the anastomosis both grossly and with the use of the SPY

Results

Eleven patients underwent esophagectomy with the aid of the SPY Imaging System. The average patient age was 56.4 ± 8.9 years (range 47–72 years). Carcinoma was biopsy proven, and upper gastrointestinal endoscopy was performed in all patients. Seven of 11 patients (64%) received neoadjuvant chemotherapy and radiation. All patients underwent a transhiatal approach with a single-layer, handsewn cervical gastroesophageal anastomosis. The average intraoperative time was 231.7 ± 30 minutes (range

Comments

There are many methods available to evaluate tissue perfusion as previously mentioned. These include the fluorescein/Wood lamp combination, conventional Doppler, laser Doppler flowmetry, single-photon emission computed tomography, mucosal oxygen saturation, conventional angiography, computed tomography angiography, and esophagogastroduodenoscopy. Each has its limitations. Technologies such as conventional Doppler/duplex have the advantage of being inexpensive but only represent the

Conclusion

Esophageal surgery continues to evolve. Still, there is a relatively high rate of morbidity and mortality associated with anastomotic leaks in esophageal reconstructive surgery. We report our initial experience using laser-induced indocyanine green tissue angiography intraoperatively for esophageal reconstructive surgery. Although this is a small and retrospective feasibility study, we believe that the technology might be useful in this setting. Its use warrants further study in a prospective

References (12)

K. Reavis
The esophageal anastomosis: how improving blood supply affects leak rate
J Gastrointest Surg
(2009)
D.M. Liebermann-Meffert et al.
Vascular anatomy of the gastric tube used for esophageal reconstruction
Ann Thorac Surg
(1992)
K. Waseda et al.
Intraoperative fluorescence imaging system for on-site assessment of off-pump coronary artery bypass graft
JACC Cardiovasc Imaging
(2009)
M. Bludau et al.
Ischemic conditioning of the gastric conduit prior to esophagectomy improves mucosal oxygen saturation
Ann Thorac Surg
(2010)
T.W. Thomas
Anastomotic stricture complicating esophagectomy
Thorac Surg Clin
(2006)
G.B. Bulkley et al.
Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (doppler and flourescein) compared with standard clinical judgment
Ann Surg
(1981)

There are more references available in the full text version of this article.

Cited by (55)

Evaluation of gastric tube blood flow by multispectral camera and fluorescence angiography
2024, Surgery Open Science
Evidence regarding the application of the multispectral camera for blood flow measurement is insufficient, and its performance has not been compared with the conventional indocyanine green (ICG) method. Therefore, we retrospectively compared the effectiveness of a new multispectral camera for non-invasive, real-time, quantitative imaging of tissue oxygen (O₂) saturation and hemoglobin (Hb) levels and commercially available ICG fluorescence imaging in hemodynamic assessment of gastric tubes in esophagectomy.
Thirty patients who underwent thoracoscopic esophagectomy and gastric tube reconstruction for esophageal cancer were included in this study. The multispectral camera was used to measure tissue O₂ saturation and Hb levels. The ICG fluorescence imaging, with the analysis software tool Lumi view, was employed to record ICG luminance changes, with values measured at the anastomotic site. Furthermore, the usefulness of each assessment device was examined using the arterial and venous blood flow indices as cutoff lines for cases with anastomotic failure.
In the evaluation of arterial perfusion, anastomotic leak occurred in three of the five (60 %) patients with arterial insufficiency as assessed by the ICG imaging, while anastomotic leakage occurred in all three patients (100 %) who were assessed as having arterial insufficiency by the multispectral camera. In the evaluation of venous perfusion, anastomotic leakage occurred in three of the nine (33.3 %) patients diagnosed with venous stasis by the IC imaging and in three of the five (60 %) patients assessed by the multispectral camera.
The multispectral camera assessed gastric tube blood flow more accurately than the ICG fluorescence method.
Indocyanine Green Use During Esophagectomy
2022, Surgical Oncology Clinics of North America
Salvage Esophagectomy
2021, Surgical Clinics of North America
Anastomotic complications after esophagectomy: Influence of omentoplasty in propensity-weighted cohorts
2020, Journal of Thoracic and Cardiovascular Surgery
A recent meta-analysis of 3 randomized controlled trials reported reduced incidence and severity of postesophagectomy anastomotic dehiscence with anastomotic omentoplasty. Unfortunately, these trials excluded neoadjuvant patients who received chemoradiation. We aimed to determine whether anastomotic omentoplasty was associated with differential postesophagectomy anastomotic complications after neoadjuvant chemoradiotherapy.
Data for patients who underwent minimally invasive esophagectomy following neoadjuvant chemoradiotherapy were abstracted (n = 245; 2001-2016; omentoplasty = 147 [60%]). Propensity for omentoplasty was estimated on 21 pretreatment variables, using augmented inverse probability of treatment weights, and used to determine the adjusted proportion of adverse anastomotic outcomes, major morbidity, and 30-day/in-hospital mortality.
Overall, anastomotic leak rate was 15%; leak-associated mortality was 13% (n = 5 out of 37). Leak rates (omentoplasty n = 24 [16%] vs no omentoplasty n = 13 [13%]; P = .512) and incidence of any major complications (48% vs 48%; P = .958) were similar. Leaks requiring surgical intervention occurred in 12 patients (5% vs 5%; P = .904). Propensity weighting achieved excellent balance across all 21 pretreatment variables (before weighting, standardized differences ranged from –0.23 to 0.35; postweighting standardized differences ranged from –0.09 to 0.07). In propensity-weighted data, omentoplasty was not associated with differential adjusted risk of anastomotic leak (13.2% vs 14.3%; P = .83), major morbidity (27.9% vs 32.6%; P = .44), or mortality (6.7% vs 4.8%; P = .61).
Within the limits of our sample size and statistical approach, our study failed to find evidence that anastomotic omentoplasty during esophagectomy after neoadjuvant chemoradiation reduced anastomotic leak rate or need for leak-related reoperation.
Current and new fluorescent probes for fluorescence-guided surgery
2020, Strategies for Curative Fluorescence-Guided Surgery of Cancer
Surgical resection is an important treatment of cancer. Despite advances in preoperative imaging, surgery itself is primarily guided by the surgeon’s ability to locate pathology by direct vision and/or palpation. Fluorescence-guided surgery (FGS) is a promising technique that is increasingly used to aid surgeons in identifying sites of tumor and surgical margins. Intraoperative visualization of tumors may not only allow more complete resections but also improve safety by avoiding unnecessary damage to normal tissue, reducing operative time and decreasing the need for second-look surgeries. A number of new FGS imaging probes have recently been developed, complementing a small but useful number of existing probes. In this review, we describe current clinical and preclinical FGS techniques and new fluorescent probes that may assist FGS.
Fluorescence-guided surgery for parathyroid gland identification
2020, Strategies for Curative Fluorescence-Guided Surgery of Cancer
Parathyroid surgery (PS) requires a great deal of knowledge of local endocrine physiology and anatomy. In order to ensure safe and adequate surgical navigation during these types of procedures, imaging tools have been developed to improve detection of parathyroid glands (PGs). Fluorescent guided surgery using indocyanine green during PS has proven to be effective in parathyroid identification, thus expediting the procedure and reducing the risk of inadvertent injury. The imaging guidance provided by this novel technology enables satisfactory outcomes in this and other types of procedures. Herein, the authors present the benefits of fluorescence-guided surgery for PG identification.

View all citing articles on Scopus

: The authors declare no conflicts of interest.

View full text

Midwest Surgical AssociationThe novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Comments

Conclusion

J Gastrointest Surg

Ann Thorac Surg

JACC Cardiovasc Imaging

Ann Thorac Surg

Anastomotic stricture complicating esophagectomy

Thorac Surg Clin

Intraoperative determination of small intestinal viability following ischemic injury: a prospective, controlled trial of two adjuvant methods (doppler and flourescein) compared with standard clinical judgment

Ann Surg

Midwest Surgical Association
The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery