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Pather K, Alabbas H, Gonzalez-Baerga C, Menendez M, Virarkar MK, de Oliveira IS, Mobley EM, Awad ZT. Major coronary artery calcifications as predictors of postoperative complications in Ivor Lewis esophagectomies: a five-year retrospective analysis. Surg Endosc 2024; 38:6865-6872. [PMID: 39187729 PMCID: PMC11527579 DOI: 10.1007/s00464-024-11181-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 08/09/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND This study aimed to determine the relationship between preoperative arterial calcifications and postoperative outcomes after Ivor Lewis esophagectomies. METHODS This was a single-center retrospective review of Ivor Lewis esophagectomies from 2013 to 2018. Preoperative CT imaging was reviewed, and arterial calcifications were graded (absent, minor, or major) in various locations. The primary outcome included major complications (defined by the Clavien-Dindo classification III-V) and the secondary outcomes were 90-day reoperations, readmissions, and mortality. Significant associations (p < 0.05) between calcifications and outcomes on univariable analysis were evaluated using a multivariable logistic regression model (odds ratios, OR; 95% confidence intervals, CI). RESULTS One hundred patients underwent esophagectomies from 2013 to 2018 (79% male, 90% White, median age 68 years), and 85% were classified as ASA III. Ninety-four patients had accessible preoperative imaging. Arterial calcifications in specific areas were observed: 82 in coronary arteries (major in 33 patients), 54 in the aortic valve, 78 in supra-aortic arteries, 79 in the thoracic aorta, 82 in the abdominal aorta, and 71 in common iliac. Furthermore, 60 patients exhibited celiac axis calcifications, with 40 patients classified as major. Twenty-five patients experienced major complications. Anastomotic leak occurred in two patients, and graft necrosis occurred in one patient. Ninety-day readmission was 10%, reoperation was 12%, and mortality was 4%. On univariable analysis, major coronary artery calcifications were significantly associated with major complications (OR 4.04; 95% CI 1.34-12.16; p = 0.02) and 90-day readmissions (OR 8.20; 95% CI 1.01-68.47; p = 0.04). However, no significant associations were identified between 90-day reoperations or mortality and arterial calcifications. CONCLUSIONS This study demonstrated that preoperative coronary calcifications increase the risk of postoperative complications, as this may be a surrogate of overall health. Nonetheless, the correlation between splanchnic calcifications and postoperative outcomes needs further exploration.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Haytham Alabbas
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, FL, 32209, USA
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Carlos Gonzalez-Baerga
- Department of Radiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Manuel Menendez
- Department of Radiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Mayur K Virarkar
- Department of Radiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Irai Santana de Oliveira
- Department of Radiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Erin M Mobley
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, FL, 32209, USA
| | - Ziad T Awad
- Department of Surgery, University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, FL, 32209, USA
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Van TN, Trong HN, Thanh SL, Gia KN, Van HP, Van DN, To HN, Anh TN. Evaluation of the gastric conduit perfusion using indocyanine green in thoracoscopic esophagectomy for esophageal cancer. SAGE Open Med 2024; 12:20503121241269631. [PMID: 39263633 PMCID: PMC11388304 DOI: 10.1177/20503121241269631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/24/2024] [Indexed: 09/13/2024] Open
Abstract
Objective Indocyanine green has been used in the assessment of the gastric conduit perfusion in thoracoscopic esophagectomy to prevent malperfusion-associated anastomotic leak. This study aims to evaluate the initial results of investigating the gastric conduit perfusion with indocyanine green in the surgical treatment of esophageal cancer. Patients and methods This cross-sectional descriptive study was carried out on 54 esophageal cancer patients undergoing thoracoscopic esophagectomy and gastric conduit reconstruction. The blood flow in the gastric conduit was observed using an infrared camera and indocyanine green after completion of the conduit and after tunneling the conduit through the mediastinum to the neck. Results The gastric conduit width and length were 5.2 ± 0.3 cm, and 31.5 ± 1.6 cm, respectively. The length of the gastric conduit from the junction between the right and left gastroepiploic to the point where the distal end of the gastric conduit still has a vascular pulse was 11.9 ± 4.3 cm. Seventeen patients (31.5%) had poor blood supply at the distal end of the gastric conduit, with indocyanine green appearance time ⩾ 60 s, in whom anastomotic leaks occurred in five patients (9.3%). The lack of connection between the right and left gastroepiploic vessels was associated with poor blood supply of the distal gastric conduit (p = 0.04). Multivariable logistic regression analysis showed association between the time of indocyanine green appearance at the distal gastric conduit and the risk of anastomotic leak (OR = 1.99, 95% CI = 1.10-3.60, p = 0.02). Conclusion Investigation of gastric conduit perfusion using indocyanine green in gastric conduit reconstruction detected 31.5% of patients with poor blood supply at the distal end of the conduit, in whom 9.3% had anastomotic leak. The longer indocyanine green appearance time in the distal gastric conduit (segment BC), was associated with the higher rate of the anastomotic leak.
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Affiliation(s)
- Tiep Nguyen Van
- Gastrointestinal Surgery Department, Digestive Surgery Center, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Hoe Nguyen Trong
- Gastrointestinal Surgery Department, Digestive Surgery Center, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Son Le Thanh
- Gastrointestinal Surgery Department, Digestive Surgery Center, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Khanh Ngo Gia
- Gastrointestinal Surgery Department, Digestive Surgery Center, Military Hospital 103, Vietnam Military Medical University, Hanoi, Vietnam
| | - Hiep Pham Van
- Department of Gastrointestinal Tract Surgery, Central Military 108 Hospital, Hanoi, Vietnam
| | - Du Nguyen Van
- Department of Gastrointestinal Tract Surgery, Central Military 108 Hospital, Hanoi, Vietnam
| | - Hoai Nguyen To
- Department of Gastrointestinal Tract Surgery, Central Military 108 Hospital, Hanoi, Vietnam
| | - Tuan Nguyen Anh
- Department of Gastrointestinal Tract Surgery, Central Military 108 Hospital, Hanoi, Vietnam
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Li ZR, Cheng YC, Hong ZJ. Diagnostic laparoscopy with indocyanine green fluorescence test for the evaluation of intestinal perfusion in abdominal blunt injury: a case report. Int J Emerg Med 2024; 17:100. [PMID: 39187750 PMCID: PMC11345953 DOI: 10.1186/s12245-024-00684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/18/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND The indocyanine green (ICG) fluorescence test has become a standard test in surgical procedures, facilitating the assessment of blood perfusion in real-time. While its utility in emergency surgeries for evaluating anastomotic blood supply is well-established, its application in trauma cases, especially those involving mesenteric hematoma, remains underexplored. Herein, we present a case to illustrate the efficacy of the ICG fluorescence test in such scenarios. CASE PRESENTATION A 51-year-old man with uncontrolled hypertension suffered blunt abdominal trauma following a motor vehicle accident. We used the intra-operative ICG fluorescence test to chart the surgical plan for the patient. A combination of diagnostic laparoscopy with ICG fluorescence testing effectively excluded bowel ischemia, leading to the avoidance of intestinal resection and the need for a temporary ostomy. The patient resumed enteral nutrition. CONCLUSIONS Our case underscores the efficacy of ICG fluorescence testing in assessing bowel viability and guiding surgical strategies in trauma patients with mesenteric hematoma. By facilitating real-time visualization of blood perfusion, ICG testing enables the adoption of conservative treatments in patients who would traditionally require more invasive surgical interventions, with minimal effect on operation time and cost.
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Affiliation(s)
- Ze-Rui Li
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Chiao Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Zhi-Jie Hong
- Division of Traumatology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Sozzi A, Bona D, Yeow M, Habeeb TAAM, Bonitta G, Manara M, Sangiorgio G, Biondi A, Bonavina L, Aiolfi A. Does Indocyanine Green Utilization during Esophagectomy Prevent Anastomotic Leaks? Systematic Review and Meta-Analysis. J Clin Med 2024; 13:4899. [PMID: 39201041 PMCID: PMC11355508 DOI: 10.3390/jcm13164899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Revised: 08/06/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Indocyanine Green (ICG) is a promising technique for the assessment of gastric conduit and anastomosis perfusion during esophagectomy. ICG integration may be helpful in minimizing the risk of anastomotic leak (AL). Literature evidence is sparse, while the real effect of ICG assessment on AL minimization remains unsolved. The aim of this systematic review and meta-analysis was to compare short-term outcomes between ICG-guided and non-ICG-guided (nICG) esophagogastric anastomosis during esophagectomy for cancer. Materials and Methods: PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried up to 25 April 2024. Studies that reported short-term outcomes for ICG versus non-ICG-guided (nICG) anastomosis in patients undergoing esophagectomy were considered. Primary outcome was AL. Risk ratio (RR) and standardized mean difference (SMD) were utilized as effect size measures, whereas to assess relative inference we used 95% confidence intervals (95% CI). Results: Overall, 1399 patients (11 observational studies) were included. Overall, 576 (41.2%) underwent ICG gastric conduit assessment. The patients' ages ranged from 22 to 91 years, with 73% being male. The cumulative incidence of AL was 10.4% for ICG and 15.4% for nICG. Compared to nICG, ICG utilization was related to a reduced risk for postoperative AL (RR 0.48; 95% CI 0.23-0.99; p = 0.05). No differences were found in terms of pulmonary complications (RR 0.83), operative time (SMD -0.47), hospital length of stay (SMD -0.16), or 90-day mortality (RR 1.70). Conclusions: Our study seems to indicate a potential impact of ICG in reducing post-esophagectomy AL. However, because of limitations in the design of the included studies, allocation/reporting bias, variable definitions of AL, and heterogeneity in ICG use, caution is required to avoid potential overestimation of the ICG effect.
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Affiliation(s)
- Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Marcus Yeow
- Department of Surgery, National University Hospital, National University Health System, 1E, Kent Ridge Road, NUHS Tower Block, Level 8, Singapore 119228, Singapore;
| | - Tamer A. A. M. Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig 7120001, Egypt;
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Giuseppe Sangiorgio
- Department of General Surgery and Medical Surgical Specialties, Surgical Division, G. Rodolico Hospital, University of Catania, 95131 Catania, Italy; (G.S.); (A.B.)
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, Surgical Division, G. Rodolico Hospital, University of Catania, 95131 Catania, Italy; (G.S.); (A.B.)
| | - Luigi Bonavina
- I.R.C.C.S. Policlinico San Donato, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, 20097 Milan, Italy;
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
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Nguyen DT, Dat TQ, Thong DQ, Hai NV, Bac NH, Long VD. Role of indocyanine green fluorescence imaging for evaluating blood supply in the gastric conduit via the substernal route after McKeown minimally invasive esophagectomy. J Gastrointest Surg 2024; 28:351-358. [PMID: 38583883 DOI: 10.1016/j.gassur.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/29/2024] [Accepted: 02/03/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) is a determining factor of morbidity and mortality after esophagectomy. Adequate perfusion of the gastric conduit is crucial for AL prevention. This study aimed to determine whether intraoperative angiography using indocyanine green (ICG) fluorescence improves the incidence of AL after McKeown minimally invasive esophagectomy (MIE) with gastric conduit via the substernal route (SR). METHODS This retrospective cohort study included 120 patients who underwent MIE with gastric conduit via SR for esophageal cancer between February 2019 and April 2023. Of 120 patients, 88 experienced intraoperative angiography using ICG (ICG group), and 32 patients experienced intraoperative angiography without ICG (no-ICG group). Baseline characteristics and operative outcomes, including AL as the main concern, were compared between the 2 groups. In addition, the outcomes among patients in the ICG group with different levels of fluorescence intensity were compared. RESULTS The ICG and no-ICG groups were comparable in baseline characteristics and operative outcomes. There was no significant difference between the 2 groups regarding the rate of AL (31.0% vs 37.5%; P = .505), median dates of AL (9 vs 9 days; P = .810), and severity of AL (88.9%, 11.11%, and 0.0% vs 66.7%, 16.7%, and 16.7% for grades I, II, and III, respectively; P = .074). Patients in the ICG group with lower intensity of ICG had higher rates of leakage (24.6%, 39.3%, and 100% in levels I, II, and III of ICG intensity, respectively; P = .04). CONCLUSION The use of ICG did not seem to reduce the rate of AL. However, abnormal intensity of ICG fluorescence was associated with a higher rate of AL, which implies a predictive potential.
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Affiliation(s)
- Doan Thuy Nguyen
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tran Quang Dat
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Dang Quang Thong
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Viet Hai
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Hoang Bac
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Vo Duy Long
- Department of Gastrointestinal Surgery, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam; Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
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Fransvea P, Chiarello MM, Fico V, Cariati M, Brisinda G. Indocyanine green: The guide to safer and more effective surgery. World J Gastrointest Surg 2024; 16:641-649. [PMID: 38577071 PMCID: PMC10989327 DOI: 10.4240/wjgs.v16.i3.641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
In this editorial we comment on the article by Kalayarasan and co-workers published in the recent issue of the World Journal of Gastrointestinal Surgery. The authors present an interesting review on the use of indocyanine green fluorescence in different aspects of abdominal surgery. They also highlight future perspectives of the use of indocyanine green in mini-invasive surgery. Indocyanine green, used for fluorescence imaging, has been approved by the Food and Drug Administration and is safe for use in humans. It can be administered intravenously or intra-arterially. Since its advent, there have been several advancements in the applications of indocyanine green, especially in the surgical field, such as intraoperative mapping and biopsy of sentinel lymph node, measurement of hepatic function prior to resection, in neurosurgical cases to detect vascular anomalies, in cardiovascular cases for patency and assessment of vascular abnormalities, in predicting healing following amputations, in helping visualization of hepatobiliary anatomy and blood vessels, in reconstructive surgery, to assess flap viability and for the evaluation of tissue perfusion following major trauma and burns. For these reasons, the intraoperative use of indocyanine green has become common in a variety of surgical specialties and transplant surgery. Colorectal surgery has just lately begun to adopt this technique, particularly for perfusion visualization to prevent anastomotic leakage. The regular use of indocyanine green coupled with fluorescence angiography has recently been proposed as a feasible tool to help improve patient outcomes. Using the best available data, it has been shown that routine use of indocyanine green in colorectal surgery reduces the rates of anastomotic leak. The use of indocyanine green is proven to be safe, feasible, and effective in both elective and emergency scenarios. However, additional robust evidence from larger-scale, high-quality studies is essential before incorporating indocyanine green guided surgery into standard practice.
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Affiliation(s)
- Pietro Fransvea
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | | | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Maria Cariati
- Department of Surgery, Azienda Sanitaria Provinciale di Crotone, Crotone 88900, Italy
| | - Giuseppe Brisinda
- Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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Nusrath S, Kalluru P, Shukla S, Dharanikota A, Basude M, Jonnada P, Abualjadayel M, Alabbad S, Mir TA, Broering DC, Raju KVVN, Rao TS, Vashist YK. Current status of indocyanine green fluorescent angiography in assessing perfusion of gastric conduit and oesophago-gastric anastomosis. Int J Surg 2024; 110:1079-1089. [PMID: 37988405 PMCID: PMC10871664 DOI: 10.1097/js9.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
Anastomotic leak (AL) remains a significant complication after esophagectomy. Indocyanine green fluorescent angiography (ICG-FA) is a promising and safe technique for assessing gastric conduit (GC) perfusion intraoperatively. It provides detailed visualization of tissue perfusion and has demonstrated usefulness in oesophageal surgery. GC perfusion analysis by ICG-FA is crucial in constructing the conduit and selecting the anastomotic site and enables surgeons to make necessary adjustments during surgery to potentially reduce ALs. However, anastomotic integrity involves multiple factors, and ICG-FA must be combined with optimization of patient and procedural factors to decrease AL rates. This review summarizes ICG-FA's current applications in assessing esophago-gastric anastomosis perfusion, including qualitative and quantitative analysis and different imaging systems. It also explores how fluorescent imaging could decrease ALs and aid clinicians in utilizing ICG-FA to improve esophagectomy outcomes.
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Affiliation(s)
| | - Prasanthi Kalluru
- Clinical Research, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | | | | | | | | | - Muayyad Abualjadayel
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Saleh Alabbad
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | | | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | | | | | - Yogesh Kumar Vashist
- Departrments of Surgical Oncology
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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Bîrlă R, Hoara P, Achim F, Dinca V, Ciuc D, Constantinoiu S, Constantin A. Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives. World J Gastrointest Oncol 2023; 15:1675-1690. [PMID: 37969407 PMCID: PMC10631441 DOI: 10.4251/wjgo.v15.i10.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/04/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.
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Affiliation(s)
- Rodica Bîrlă
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Petre Hoara
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Florin Achim
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Valeriu Dinca
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Diana Ciuc
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Adrian Constantin
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
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Abdelrahman H, El-Menyar A, Peralta R, Al-Thani H. Application of indocyanine green in surgery: A review of current evidence and implementation in trauma patients. World J Gastrointest Surg 2023; 15:757-775. [PMID: 37342859 PMCID: PMC10277941 DOI: 10.4240/wjgs.v15.i5.757] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
Background: Modern surgical medicine strives to manage trauma while improving outcomes using functional imaging. Identification of viable tissues is crucial for the surgical management of polytrauma and burn patients presenting with soft tissue and hollow viscus injuries. Bowel anastomosis after trauma-related resection is associated with a high rate of leakage. The ability of the surgeon’s bare eye to determine bowel viability remains limited, and the need for a more standardized objective assessment has not yet been fulfilled. Hence, there is a need for more precise diagnostic tools to enhance surgical evaluation and visualization to aid early diagnosis and timely management to minimize trauma-associated complications. Indocyanine green (ICG) coupled with fluorescence angiography is a potential solution for this problem. ICG is a fluorescent dye that responds to near-infrared irradiation. Methods: We conducted a narrative review to address the utility of ICG in the surgical management of patients with trauma as well as elective surgery. Discussion: ICG has many applications in different medical fields and has recently become an important clinical indicator for surgical guidance. However, there is a paucity of information regarding the use of this technology to treat traumas. Recently, angiography with ICG has been introduced in clinical practice to visualize and quantify organ perfusion under several conditions, leading to fewer cases of anastomotic insufficiency. This has great potential to bridge this gap and enhance the clinical outcomes of surgery and patient safety. However, there is no consensus on the ideal dose, time, and manner of administration nor the indications that ICG provides a genuine advantage through greater safety in trauma surgical settings. Conclusions: There is a scarcity of publications describing the use of ICG in trauma patients as a potentially useful strategy to facilitate intraoperative decisions and to limit the extent of surgical resection. This review will improve our understanding of the utility of intraoperative ICG fluorescence in guiding and assisting trauma surgeons to deal with the intraoperative challenges and thus improve the patients’ operative care and safety in the field of trauma surgery.
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Affiliation(s)
| | - Ayman El-Menyar
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Ruben Peralta
- Trauma Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Hassan Al-Thani
- Trauma and Vascular Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Cassinotti E, Al-Taher M, Antoniou SA, Arezzo A, Baldari L, Boni L, Bonino MA, Bouvy ND, Brodie R, Carus T, Chand M, Diana M, Eussen MMM, Francis N, Guida A, Gontero P, Haney CM, Jansen M, Mintz Y, Morales-Conde S, Muller-Stich BP, Nakajima K, Nickel F, Oderda M, Parise P, Rosati R, Schijven MP, Silecchia G, Soares AS, Urakawa S, Vettoretto N. European Association for Endoscopic Surgery (EAES) consensus on Indocyanine Green (ICG) fluorescence-guided surgery. Surg Endosc 2023; 37:1629-1648. [PMID: 36781468 PMCID: PMC10017637 DOI: 10.1007/s00464-023-09928-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND In recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community. METHODS An expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021. RESULTS A total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications. CONCLUSIONS Overall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.
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Affiliation(s)
- E Cassinotti
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, University of Milan, Via Francesco Sforza 35, 20121, Milan, Italy.
| | - M Al-Taher
- Research Institute Against Digestive Cancer (IRCAD), Strasbourg, France
| | - S A Antoniou
- Department of Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | - A Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - L Baldari
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, University of Milan, Via Francesco Sforza 35, 20121, Milan, Italy
| | - L Boni
- Department of General and Minimally Invasive Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, University of Milan, Via Francesco Sforza 35, 20121, Milan, Italy
| | - M A Bonino
- Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - R Brodie
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - T Carus
- Niels-Stensen-Kliniken, Elisabeth-Hospital, Thuine, Germany
| | - M Chand
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - M Diana
- IHU Strasbourg, Institute of Image-Guided Surgery and IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France
| | - M M M Eussen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - N Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - A Guida
- Department of Medico-Surgical Sciences and Translation Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - P Gontero
- Division of Urology, Department of Surgical Science, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - C M Haney
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M Jansen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Y Mintz
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General Surgery, University Hospital Virgen del Rocío, University of Sevilla, Seville, Spain
| | - B P Muller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - K Nakajima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - F Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M Oderda
- Division of Urology, Department of Surgical Science, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - P Parise
- U.O.C. Chirurgia Generale, Policlinico di Abano Terme, Abano Terme, PD, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital, Milan, Italy
| | - M P Schijven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, North Holland, The Netherlands
- Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health, Digital Health, Amsterdam UMC, Amsterdam, North Holland, The Netherlands
| | - G Silecchia
- Department of Medico-Surgical Sciences and Translation Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - A S Soares
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - S Urakawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - N Vettoretto
- U.O.C. Chirurgia Generale, ASST Spedali Civili di Brescia P.O. Montichiari, Ospedale di Montichiari, Montichiari, Italy
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11
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Indocyanine Green Use During Esophagectomy. Surg Oncol Clin N Am 2022; 31:609-629. [DOI: 10.1016/j.soc.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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12
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Hung PC, Chen HY, Tu YK, Kao YS. A Comparison of Different Types of Esophageal Reconstructions: A Systematic Review and Network Meta-Analysis. J Clin Med 2022; 11:jcm11175025. [PMID: 36078955 PMCID: PMC9457433 DOI: 10.3390/jcm11175025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: A total esophagectomy with gastric tube reconstruction is the mainstream procedure for esophageal cancer. Colon interposition and free jejunal flap for esophageal reconstruction are the alternative choices when the gastric tube is not available. However, to date, a solution for the high anastomosis leakage rates among these three types of conduits has not been reported. The aim of this network meta-analysis was to investigate the rate of anastomotic leakage (AL) among the three procedures to determine the best esophageal substitute or the future direction for improving the conventional gastric pull-up (GPU). Methods: We searched PubMed, Cochrane, and Embase databases. We included esophageal cancer patients receiving esophagectomy and excluded patients with other cancer. The random effect model was used in this network meta-analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment of studies in the network meta-analysis, and funnel plots were used to evaluate publication bias. The primary outcome is anastomosis leakage; the secondary outcomes are stricture formation, length of hospital stays, and mortality rate. Results: Nine studies involving 1613 patients were included in this network meta-analysis. The trend results indicated the following. Regarding anastomosis leakage, free jejunal flap was the better procedure; regarding stricture formation, colon interposition was the better procedure; regarding mortality rate, free jejunal flap was the better procedure; regarding length of hospital stay, gastric pull-up was the better treatment. Discussion: Overall, if technically accessible, free jejunal flap is a better choice than colon interposition when gastric conduit cannot be used, but further study should be conducted to compare groups with equal supercharged patients. In addition, jejunal flap (JF) cannot replace traditional gastric pull-up (GPU) due to technical complexities, more anastomotic sites, and longer operation times. However, the GPU method with the supercharged procedure would be a possible solution to lower postoperative AL. The limitation of this meta-analysis is that the number of articles included was low; we aim to update the result when new data are available. Funding: None. Registration: N/A.
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Affiliation(s)
- Pang-Chieh Hung
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Hsuan-Yu Chen
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 106, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence:
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13
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Ekman M, Girnyi S, Marano L, Roviello F, Chand M, Diana M, Polom K. Near-Infrared Fluorescence Image-Guided Surgery in Esophageal and Gastric Cancer Operations. Surg Innov 2022; 29:540-549. [PMID: 35285305 DOI: 10.1177/15533506211073417] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2025]
Abstract
BACKGROUND Near-infrared fluorescence image-guided surgery helps surgeons to see beyond the classical eye vision. Over the last few years, we have witnessed a revolution which has begun in the field of image-guided surgery. PURPOSE, AND RESEARCH DESIGN Fluorescence technology using indocyanine green (ICG) has shown promising results in many organs, and in this review article, we wanted to discuss the 6 main domains where fluorescence image-guided surgery is currently used for esophageal and gastric cancer surgery. STUDY SAMPLE AND DATA COLLECTION Visualization of lymphatic vessels, tumor localization, fluorescence angiography for anastomotic evaluation, thoracic duct visualization, tracheal blood flow analysis, and sentinel node biopsy are discussed. CONCLUSIONS It seems that this technology has already found its place in surgery. However, new possibilities and research avenues in this area will probably make it even more important in the near future.
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Affiliation(s)
- Marcin Ekman
- Department of Surgical Oncology, 37804Medical University of Gdansk, Gdansk, Poland
| | - Sergii Girnyi
- Department of Surgical Oncology, 37804Medical University of Gdansk, Gdansk, Poland
| | - Luigi Marano
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, 243257University of Siena, Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, 243257University of Siena, Siena, Italy
| | - Manish Chand
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), 4919University College London, London
| | - Michele Diana
- Department of Surgical Oncology, 37804Medical University of Gdansk, Gdansk, Poland
- Department of Medicine, Surgery and Neurosciences, Unit of General Surgery and Surgical Oncology, 243257University of Siena, Siena, Italy
- Wellcome EPSRC Centre for Interventional and Surgical Sciences (WEISS), 4919University College London, London
| | - Karol Polom
- Department of Surgical Oncology, 37804Medical University of Gdansk, Gdansk, Poland
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14
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Tamburini N, Chiozza M, Maniscalco P, Resta G, Marino S, Quarantotto F, Anania G, Cavallesco G. Application of Indocyanine Green Enhanced Fluorescence in Esophageal Surgery: A Mini Review. Front Surg 2022; 9:961856. [PMID: 35874138 PMCID: PMC9304659 DOI: 10.3389/fsurg.2022.961856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Despite recent technological innovations and the development of minimally invasive surgery, esophagectomy remains an operation burdened with severe postoperative complications. Fluorescence imaging, particularly using indocyanine green (ICG), offers the ability to address a number of issues faced during esophagectomy. The three main indications for the intraoperative use of ICG during esophagectomy are visualization of conduit vascular supply, allow identification of sentinel nodes and visualization of the thoracic duct. The purpose of this mini review is to present an overview of current practice in fluorescence imaging utilizing ICG during esophagectomy, as well as to demonstrate how this technology can guide lymphadenectomy and reduce surgical morbidity such as anastomotic leaking and chylothorax.
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15
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Hong ZN, Huang L, Zhang W, Kang M. Indocyanine Green Fluorescence Using in Conduit Reconstruction for Patients With Esophageal Cancer to Improve Short-Term Clinical Outcome: A Meta-Analysis. Front Oncol 2022; 12:847510. [PMID: 35719988 PMCID: PMC9198426 DOI: 10.3389/fonc.2022.847510] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives This meta-analysis evaluated the short-term safety and efficacy of indocyanine green (ICG) fluorescence in gastric reconstruction to determine a suitable anastomotic position during esophagectomy. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyzes 2020 (PRISMA) were followed for this analysis. Results A total of 9 publications including 1,162 patients were included. The operation time and intraoperative blood loss were comparable in the ICG and control groups. There was also no significant difference in overall postoperative mortality, reoperation, arrhythmia, vocal cord paralysis, pneumonia, and surgical wound infection. The ICG group had a 2.66-day reduction in postoperative stay. The overall anastomotic leak (AL) was 17.6% (n = 131) in the control group and 4.5% (n = 19) in the ICG group with a relative risk (RR) of 0.29 (95% CI 0.18–0.47). A subgroup analysis showed that the application of ICG in cervical anastomosis significantly reduced the incidence of AL (RR of 0.31, 95% CI 0.18–0.52), but for intrathoracic anastomosis, the RR 0.35 was not significant (95% CI 0.09–1.43). Compared to an RR of 0.35 in publications with a sample size of <50, a sample size of >50 had a lower RR of 0.24 (95% CI 0.12–0.48). Regarding intervention time of ICG, the application of ICG both before and after gastric construction had a better RR of 0.25 (95% CI 0.07–0.89). Conclusions The application of ICG fluorescence could effectively reduce the incidence of AL and shorten the postoperative hospital stay for patients undergoing cervical anastomosis but was not effective for patients undergoing intrathoracic anastomosis. The application of ICG fluorescence before and after gastric management can better prevent AL. Systematic Review Registration PROSPERO, CRD:42021244819.
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Affiliation(s)
- Zhi-Nuan Hong
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Liqin Huang
- Department of Equipment, Fujian Medical University Union Hospital, Fuzhou, China
| | - Weiguang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China.,Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China.,Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
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16
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Schlottmann F, Angeramo CA, Bras Harriott C, Casas MA, Herbella FAM, Patti MG. Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2022; 32:380-392. [PMID: 35583556 DOI: 10.1097/sle.0000000000001050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/12/2021] [Indexed: 12/08/2022]
Abstract
BACKGROUND Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis. MATERIALS AND METHODS A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes. RESULTS A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively. CONCLUSION HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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17
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von Kroge P, Russ D, Wagner J, Grotelüschen R, Reeh M, Izbicki JR, Mann O, Wipper SH, Duprée A. Quantification of gastric tube perfusion following esophagectomy using fluorescence imaging with indocyanine green. Langenbecks Arch Surg 2022; 407:2693-2701. [PMID: 35581393 DOI: 10.1007/s00423-022-02546-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) remains a prevalent and life-threatening complication after esophagectomy. Gastric tube perfusion assessment using indocyanine green fluorescence imaging (ICG-FI) has been published in several studies and appears to be a promising tool to reduce AL rates by changing the surgical approach, namely by an intraoperative evaluation of the anastomosis localization. METHODS In this study, gastric tube perfusion was quantified by using ICG-FI in 20 high-risk patients undergoing esophagectomy. From a time-dependent fluorescence intensity curve, the following three parameters were evaluated: slope of fluorescence intensity (SFI), background subtracted peak fluorescence intensity (BSFI), and time to slope (TTS). RESULTS The values between pyloric region and tip showed a similar downward trend and SFI and BSFI significantly correlated with the distance to the pyloric region. SFI and BSFI were significantly decreased at the tip of the gastric tube. The placement of anastomosis in an area with homogenous fluorescence pattern was correlated with no AL in 92.9% of cases. An inhomogeneous fluorescence pattern at anastomotic site was a risk factor for the occurrence of an AL (p < 0.05). Reduction of perfusion up to 32% using SFI and up to 23% using BSFI was not associated with AL. CONCLUSION ICG-FI can be used to quantify the gastric tube perfusion by calculating SFI, BSFI, and TTS. The anastomosis should be created in areas with homogeneous fluorescence pattern. A reduction in blood flow of up to 32% can be accepted without causing an increased rate of insufficiency.
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Affiliation(s)
- Philipp von Kroge
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Detlef Russ
- Department for the Development of Applications, Institute for Laser Technology, University Ulm, Ulm, Germany
| | - Jonas Wagner
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Grotelüschen
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine H Wipper
- Department of Vascular Surgery, University Medical Center Innsbruck, Innsbruck, Austria
| | - Anna Duprée
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Lee SL, Jeon CH, Park KB, Seo HS, Lee HH. Association between Vascular Calcification and Esophagojejunal Anastomotic Complications after Total Gastrectomy for Gastric Cancer: A Propensity-Matched Study. Curr Oncol 2022; 29:3224-3231. [PMID: 35621652 PMCID: PMC9140084 DOI: 10.3390/curroncol29050262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022] Open
Abstract
Esophagojejunal anastomosis (EJA) complications after total gastrectomy are related to significant morbidity and mortality. The aim of this study was to evaluate the association between arterial calcifications and EJA complications such as leak and stricture for gastric cancer. Between January 2014 and October 2019, 30 patients with EJA complications after total gastrectomy were enrolled and matched to 30 patients without complications through retrospective data review. Arterial calcification grade on preoperative computed tomography (CT) was reported in the abdominal aorta and superior mesenteric artery (SMA) as “absent”, “minor”, or “major”, and in the jejunal vascular arcade (JVA) and left inferior phrenic artery (LIPA) as “absent” or “present”. A Chi-square test was used to compare the variables between the two groups. p-Value < 0.050 was considered statistically significant. Among 30 patients, the numbers of patients with leak and stricture were 23 and seven, respectively. Aortic calcifications were not associated with EJA complications regardless of their grade (p = 0.440). Only major SMA calcifications were associated with EJA complications, as they were present in five patients (16.7%) in the complication group and absent in the non-complication group (p = 0.020). Major SMA calcifications were more related to anastomotic stricture than leak. Three (13.0%) out of 23 patients with leak and two (28.6%) out of seven with stricture had major SMA calcifications (p = 0.028). No calcifications were detected in the JVA or LIPA in any of the 60 patients. Major SMA calcifications were found to be associated with EJA complications, especially in stricture.
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Affiliation(s)
- Su-Lim Lee
- Department of Radiology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si 11765, Korea;
| | - Chul-Hyo Jeon
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea; (C.-H.J.); (K.-B.P.); (H.-S.S.)
| | - Ki-Bum Park
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea; (C.-H.J.); (K.-B.P.); (H.-S.S.)
| | - Ho-Seok Seo
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea; (C.-H.J.); (K.-B.P.); (H.-S.S.)
| | - Han-Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea; (C.-H.J.); (K.-B.P.); (H.-S.S.)
- Correspondence: ; Tel.: +82-10-4326-6039 or +82-2-2258-6106; Fax: +82-2-595-2282
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19
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Casas MA, Angeramo CA, Bras Harriott C, Dreifuss NH, Schlottmann F. Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2022; 35:6347566. [PMID: 34378016 DOI: 10.1093/dote/doab056] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/07/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis. METHODS A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes. RESULTS A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29). CONCLUSION The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.
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Affiliation(s)
- María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Cristian A Angeramo
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.,Division of Esophageal and Gastric Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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20
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Near-infrared fluorescence imaging with indocyanine green to assess the blood supply of the reconstructed gastric conduit to reduce anastomotic leakage after esophagectomy: a literature review. Surg Today 2022; 53:399-408. [PMID: 35182253 DOI: 10.1007/s00595-022-02474-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 01/09/2022] [Indexed: 02/05/2023]
Abstract
The blood supply of the right gastroepiploic artery after esophagectomy with gastric tube reconstruction is essential for avoiding anastomotic leakage. Near-infrared fluorescence (NIRF) imaging with indocyanine green is widely used to assess the blood supply because it can visualize it in real-time during navigation surgery. However, there is no established protocol for this modality. One reason for this lack of protocol is that NIRF provides subjective information. This study aimed to evaluate NIRF quantification. We conducted a literature review of risk factors for anastomotic leakage after esophagectomy, NIRF procedures, NIRF quantification, and new methods to compensate for NIRF limitations. Major methods for the quantification of NIRF include measuring the blood flow speed, visualization time, and fluorescence intensity. The cutoff value for the blood flow speed is 2.07 cm/s, and that for the visualization time is 30-90 s. Although the time-intensity curve provided patterns of change in the blood flow, it did not show an association with anastomotic leakage. However, to compensate for the limitations of NIRF, new devices have been reported that can assess tissue oxygenation perfusion, organ hemoglobin concentration, and microcirculation.
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21
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Van Daele E, De Bruyne N, Vanommeslaeghe H, Van Nieuwenhove Y, Ceelen W, Pattyn P. Clinical utility of near-infrared perfusion assessment of the gastric tube during Ivor Lewis esophagectomy. Surg Endosc 2022; 36:5812-5821. [PMID: 35157124 DOI: 10.1007/s00464-022-09091-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 01/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) after Ivor Lewis esophagectomy with intrathoracic anastomosis carries a significant morbidity. Adequate perfusion of the gastric tube (GT) is an important predictor of anastomotic integrity. Recently, near infrared fluorescent (NIRF) imaging using indocyanine green (ICG) was introduced in clinical practice to evaluate tissue perfusion. We evaluated the feasibility and efficacy of GT indocyanine green angiography (ICGA) after Ivor Lewis esophagectomy. METHODS This retrospective analysis used data from a prospectively kept database of consecutive patients who underwent Ivor Lewis (IL) esophagectomy with GT construction for cancer between January 2016 and December 2020. Relevant outcomes were feasibility, ICGA complications and the impact of ICGA on AL. RESULTS 266 consecutive IL patients were identified who matched the inclusion criteria. The 115 patients operated with perioperative ICGA were compared to a control group in whom surgery was performed according to the standard of care. ICGA perfusion assessment was feasible and safe in all 115 procedures and suggested a poorly perfused tip in 56/115 (48.7%) cases, for which additional resection was performed. The overall AL rate was 16% (43/266), with 12% (33/266) needing an endoscopic our surgical intervention and 6% (17/266) needing ICU support. In univariable and multivariable analyses, ICGA was not correlated with the risk of AL (ICGA:14.8% vs non-ICGA:17.2%, p = 0.62). However, poor ICGA perfusion of the GT predicted a higher AL rate, despite additional resection of the tip (ICGA poorly perfused: 19.6% vs ICG well perfused: 10.2%, p = 0.19). CONCLUSIONS ICGA is safe and feasible, but did not result in a reduction of AL. The interpretation and necessary action in case of perioperative presence of ischemia on ICGA have yet to be determined. Prospective randomized trials are warranted to analyze its benefit on AL in esophageal surgery. Trial registration Ethical approval for a prospective esophageal surgery database was granted by the Ethical committee of the Ghent University Hospital. Belgian registration number: B670201111232. Ethical approval for this retrospective data analysis was granted by our institutional EC. Registration number: BC-09216.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium.
| | - Naomi De Bruyne
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, 2K12 IC, Corneel Heymanslaan 10, B-9000, Ghent, Belgium
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22
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Harriott CB, Angeramo CA, Casas MA, Schlottmann F. Open vs. Hybrid vs. Totally Minimally Invasive Ivor Lewis Esophagectomy: Systematic Review and Meta-analysis. J Thorac Cardiovasc Surg 2022; 164:e233-e254. [DOI: 10.1016/j.jtcvs.2021.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/03/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023]
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Matson J, Lwin TM, Bouvet M. Rapid intraoperative perfusion assessment of parathyroid adenomas with ICG using a wide-field portable hand-held fluorescence imaging system. Am J Surg 2021; 223:686-693. [PMID: 34407918 DOI: 10.1016/j.amjsurg.2021.07.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/27/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Fluorescence angiography (FA) using indocyanine green dye (ICG) has recently been introduced for real-time identification of parathyroid adenomas. However, time to peak fluorescence has not yet been critically evaluated. METHODS This was a retrospective review of parathyroidectomies with ICG FA over a one-year period. RESULTS There were 66 patients with average age of 64 years. The average time to initial fluorescence was 26.7 s and to peak fluorescence was 38.0 s. The time to saline flush administration significantly correlated with times to initial and peak fluorescence (p < .0001). The rate of in-situ fluorescence was 97%. The rates of suspected adenoma detection were 69% for sestamibi scan, 71% for ultrasound, and 96% for CT scan. Imaging was discordant in 13 cases (20%), with the adenoma located on the opposite side of the neck in 4 cases. CONCLUSIONS ICG FA is a rapid and effective adjunct for the intraoperative identification of parathyroid adenomas.
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Affiliation(s)
- Jared Matson
- Department of Surgery, UC San Diego, San Diego, CA, USA
| | - Thinzar M Lwin
- Department of Surgery, UC San Diego, San Diego, CA, USA; Department of Surgical Oncology, Dana Farber Cancer Center, Boston, MA, USA
| | - Michael Bouvet
- Department of Surgery, UC San Diego, San Diego, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA.
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24
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Vettoretto N, Foglia E, Ferrario L, Gerardi C, Molteni B, Nocco U, Lettieri E, Molfino S, Baiocchi GL, Elmore U, Rosati R, Currò G, Cassinotti E, Boni L, Cirocchi R, Marano A, Petz WL, Arezzo A, Bonino MA, Davini F, Biondi A, Anania G, Agresta F, Silecchia G. Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary. Surg Endosc 2021; 34:3270-3284. [PMID: 32274626 DOI: 10.1007/s00464-020-07542-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.
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Affiliation(s)
- N Vettoretto
- Chirurgia Montichiari, Azienda Socio Sanitaria Territoriale Degli Spedali Civili, V.le Ciotti 154, Montichiari, 25018, Brescia, Italy.
| | - E Foglia
- LIUC - Università Cattaneo, Castellanza, VA, Italy
| | - L Ferrario
- LIUC - Università Cattaneo, Castellanza, VA, Italy
| | - C Gerardi
- Centro di Politiche Regolatorie, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - B Molteni
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - U Nocco
- Ingegneria Clinica, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - E Lettieri
- School of Management, Department of Management, Economics and Industrial Engineering, Politecnico, Milano, Italy
| | - S Molfino
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - G L Baiocchi
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - U Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - G Currò
- Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
| | - E Cassinotti
- Chirurgia Generale, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - L Boni
- Chirurgia Generale, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - R Cirocchi
- Department of Surgical Sciences, University of Perugia, Perugia, Italy
| | - A Marano
- Chirurgia Generale ed Oncologica, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
| | - W L Petz
- Chirurgia, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - A Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - M A Bonino
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - F Davini
- Centro multidisciplinare Chirurgia Robotica, Chirurgia Toracica mini-invasiva e Robotica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - A Biondi
- Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - G Anania
- Chirurgia Generale, University of Ferrara, Ferrara, Italy
| | - F Agresta
- Chirurgia Generale, Azienda ULSS 5 "Polesana", Hospital of Adria, Adria, RO, Italy
| | - G Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome-Polo Pontino, Rome, Italy
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Koyanagi K, Ozawa S, Ninomiya Y, Yatabe K, Higuchi T, Yamamoto M, Kanamori K, Tajima K. Indocyanine green fluorescence imaging for evaluating blood flow in the reconstructed conduit after esophageal cancer surgery. Surg Today 2021; 52:369-376. [PMID: 33977382 DOI: 10.1007/s00595-021-02296-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/27/2021] [Indexed: 11/26/2022]
Abstract
We investigated the effectiveness of indocyanine green (ICG) fluorescence blood flow imaging of the gastric conduit to evaluate anastomotic leakage after esophagectomy. We identified 19 articles using the PRISMA standard for systematic reviews. The more recent studies reported attempts at objective quantification of ICG fluorescence imaging, rather than qualitative assessment. Anastomotic leakage after esophagectomy occurred in 0-33% of the patients who underwent ICG fluorescence imaging. According to the six studies that compared the incidence of anastomotic leakage in the ICG group and the control group, it ranged from 0 to 18.3% in the ICG group and from 0 to 25.2% in the control group, respectively. Overall, the incidence of anastomotic leakage in the ICG group (8.4%) was lower than that in the control group (18.5%). Although the incidence of anastomotic leakage was as high as 43.1% in patients who did not undergo any intraoperative intervention for poor blood flow, it was only 24% in patients who underwent intraoperative intervention. This systematic review revealed that ICG fluorescence imaging may be a crucial adjunctive tool for reducing anastomotic leakage after esophagectomy, suggesting that it should be performed during esophageal reconstruction.
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Affiliation(s)
- Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Kanamori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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26
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The evaluation of the gastric tube blood flow by indocyanine green fluorescence angiography during esophagectomy: a multicenter prospective study. Gen Thorac Cardiovasc Surg 2021; 69:1118-1124. [PMID: 33929678 DOI: 10.1007/s11748-021-01640-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting. METHODS We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared. RESULTS In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09). CONCLUSIONS Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.
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Gao W, Wang M, Su P, Zhang F, Huang C, Tian Z. Risk Factors of Cervical Anastomotic Leakage after McKeown Minimally Invasive Esophagectomy: Focus on Preoperative and Intraoperative Lung Function. Ann Thorac Cardiovasc Surg 2021; 27:75-83. [PMID: 33087661 PMCID: PMC8058540 DOI: 10.5761/atcs.oa.20-00139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Cervical anastomotic leakage (CAL) is one of the most common complications that occur minimally invasive esophagectomy (MIE). It is associated with high postoperative mortality. Some risk factors still remained controversial and so accurate prediction of risk groups for CAL remained very difficult. This study aimed to identify the risk factors of CAL after McKeown MIE to predict the accuracy of the technique as early as possible. Material and Methods: A total of 129 patients with esophageal cancer who underwent McKeown MIE at the Department of Thoracic Surgery, the Fourth Hospital of Hebei Medical University, between January 2018 and June 2019 were retrospectively reviewed. Multivariate logistic regression analysis was used to identify the risk factors for CAL and receiver operating characteristic (ROC) curve analysis was used to predict the accuracy for each quantitative data variable and determine the cutoff value. Results: There were statistically significant differences between Group CAL and Group NCAL in FEV1 (p = 0.031), neoadjuvant chemotherapy (p = 0.001), intraoperative minimum PaCO2 (p = 0.002), and hospital stays (p <0.001). In multivariate logistic regression, FEV1 (OR = 0.440, p = 0.047), neoadjuvant chemotherapy (OR = 4.425, p = 0.003), and intraoperative minimum PaCO2 (OR = 1.14, p <0.001) were identified to be three risk factors of CAL. The ROC curve analysis showed that FEV1 <2.18L (p = 0.029) and intraoperative minimum PaCO2 >45.5 mmHg (p = 0.002) demonstrated good accuracy. Conclusion: FEV1, neoadjuvant chemotherapy, and intraoperative minimum PaCO2 in arterial blood gas (ABG) were considered as risk factors of CAL after McKeown MIE for esophageal cancer. Preoperative FEV1 <2.18L and intraoperative minimum PaCO2 >45.5 mmHg in ABG showed good accuracy in predicting risk factors for CAL.
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Affiliation(s)
- Wenda Gao
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Mingbo Wang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Peng Su
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Fan Zhang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chao Huang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ziqiang Tian
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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28
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Pather K, Deladisma AM, Guerrier C, Kriley IR, Awad ZT. Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy. Surg Endosc 2021; 36:896-903. [PMID: 33580319 DOI: 10.1007/s00464-021-08346-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. METHODS We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). RESULTS 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260 mL [95-463] versus 75 mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. CONCLUSION Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Adeline M Deladisma
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA
| | | | - Isaac R Kriley
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA
| | - Ziad T Awad
- Department of Surgery, UF Health, 653 West 8th Street, Jacksonville, FL, 32209, USA.,University of Florida, Jacksonville, FL, USA
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29
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Luo RJ, Zhu ZY, He ZF, Xu Y, Wang YZ, Chen P. Efficacy of Indocyanine Green Fluorescence Angiography in Preventing Anastomotic Leakage After McKeown Minimally Invasive Esophagectomy. Front Oncol 2021; 10:619822. [PMID: 33489925 PMCID: PMC7821423 DOI: 10.3389/fonc.2020.619822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/30/2020] [Indexed: 12/21/2022] Open
Abstract
Background Indocyanine green (ICG) fluorescence angiography (FA) was introduced to provide real-time intraoperative evaluation of the vascular perfusion of the gastric conduit during esophagectomy. However, its efficacy has not yet been proven. The aim of this study was to assess the usefulness of ICG-FA in the reduction of the rates of anastomotic leakage (AL) in McKeown minimally invasive esophagectomy (MIE). Methods From June 2017 to December 2019, patients aged between 18 and 80 years with esophageal carcinoma were enrolled in the study and each patient underwent McKeown MIE. Patients were divided into two groups, those with or without ICG-FA. The patient demographics and perioperative outcomes were comparable between the two groups. The primary outcome was the rate of AL. Results A total of 192 patients were included: 86 in the ICG-FA group and 106 in the non-ICG-FA group. Overall, 12 patients (6.3%) had AL; the rate of AL was 10.4% in the non-ICG-FA group, which was significantly higher than the 1.2% in the ICG-FA group. Conclusions ICG-FA has the potential to reduce the rate of AL in McKeown MIE.
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Affiliation(s)
- Rao-Jun Luo
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zi-Yi Zhu
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zheng-Fu He
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yong Xu
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yun-Zheng Wang
- Department of Thoracic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ping Chen
- Zhejiang Provincial Key Laboratory of Laparoscopic Technology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Le-Nguyen A, O'Neill Trudeau M, Dodin P, Keezer MR, Faure C, Piché N. The Use of Indocyanine Green Fluorescence Angiography in Pediatric Surgery: A Systematic Review and Narrative Analysis. Front Pediatr 2021; 9:736242. [PMID: 34589458 PMCID: PMC8473799 DOI: 10.3389/fped.2021.736242] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/18/2021] [Indexed: 12/18/2022] Open
Abstract
Purpose: Indocyanine green fluorescence angiography (ICG-FA) is a validated non-invasive imaging technique used to assess tissue vascularization and guide intraoperative decisions in many surgical fields including plastic surgery, neurosurgery, and general surgery. While this technology is well-established in adult surgery, it remains sparsely used in pediatric surgery. Our aim was to systematically review and provide an overview of all available evidence on the perioperative use of indocyanine green fluorescence angiography in pediatric surgical patients. Methods: We conducted a systematic review with narrative synthesis in conformity with the PRISMA guidelines using PubMed, Medline, All EBM Reviews, EMBASE, PsycINFO, and CINAHL COMPLETE databases to identify articles describing the perioperative use of ICG-FA in pediatric patients. Two independent authors screened all included articles for eligibility and inclusion criteria. We extracted data on study design, demographics, surgical indications, indocyanine green dose, and perioperative outcomes. We developed a risk of bias assessment tool to evaluate the methodological quality of included studies. Results: Of 1,031 articles retrieved, a total of 64 articles published between 2003 and 2020 were included reporting on 664 pediatric patients. Most articles were case reports and case series (n = 36; 56%). No adverse events related to ICG-FA were reported in the included articles. Risk of bias was high. We did not conduct a meta-analysis given the heterogeneous nature of the populations, interventions, and outcome measures. A narrative synthesis is presented. Conclusion: Indocyanine green fluorescence angiography is a safe imaging technology and its use is increasing rapidly in pediatric surgical specialties. However, the quality of evidence supporting this trend currently appears low. Case-control and randomized trials are needed to determine the adequate pediatric dose and to confirm the potential benefits of ICG-FA in pediatric surgical patients. Systematic Review Registration: This study was registered on Prospero a priori, identifier: CRD42020151981.
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Affiliation(s)
- Annie Le-Nguyen
- Department of General Surgery, Université de Montréal, Montréal, QC, Canada
| | - Maeve O'Neill Trudeau
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Philippe Dodin
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Mark R Keezer
- Department of Neurosciences, Université de Montréal, Montréal, QC, Canada.,Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada.,School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Christophe Faure
- Department of Gastroenterology, Hepatology, and Nutrition, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Nelson Piché
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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31
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Sohda M, Saito H, Kumakura Y, Honjyo H, Hara K, Sakai M, Miyazaki T, Kanemoto M, Tobe M, Hinohara H, Saito S, Kuwano H. Postoperative hemodynamic changes for predicting anastomotic leakage after esophagectomy in patients with esophageal cancer using the FloTrac system. THE JOURNAL OF MEDICAL INVESTIGATION 2020; 67:240-245. [PMID: 33148895 DOI: 10.2152/jmi.67.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : Anastomotic leakage after esophagectomy is significantly associated with more severe complications, such as sepsis and mortality. Early prediction for anastomotic leakage is usually difficult and needs to be treated rapidly. In the current study, we investigated the correlation between hemodynamic and several complications after esophagectomy in patients with esophageal cancer, using the FloTrac system. Materials and Methods : Between April 2013 and December 2014, 39 patients with a mean age of 66.6 ± 8.9 years underwent postoperative supervision using the FloTrac sensor / Vigileo monitoring system after curative surgery for esophageal cancer. We retrospectively evaluated the association between the number of aberrant cardiac index (CI) along with stroke volume variability (SVV) values and clinicopathological parameters of postoperative complications in this report. Results : There were significant positive correlations between the number of aberrant values of CI along with SVV and depth of invasion during pathological stage. Concerning major postoperative complications, there was a significant positive correlation between the number of aberrant values of CI and anastomotic leakage. Discussion: The hemodynamic change by employing the FloTrac system could predicts the complication of anastomotic leakage after esophagectomy. Adequate management of hemodynamic stability by utilizing it will reduce the complications of anastomotic leakage. J. Med. Invest. 67 : 240-245, August, 2020.
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Affiliation(s)
- Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Hideyuki Saito
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Yuji Kumakura
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Hiroaki Honjyo
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Keigo Hara
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Masafumi Kanemoto
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Masaru Tobe
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Hiroshi Hinohara
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Shigeru Saito
- Department of Anesthesiology, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
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32
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Griffin SM, Jones R, Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Phillips AW. Evolution of Esophagectomy for Cancer Over 30 Years: Changes in Presentation, Management and Outcomes. Ann Surg Oncol 2020; 28:3011-3022. [PMID: 33073345 PMCID: PMC8119401 DOI: 10.1245/s10434-020-09200-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/03/2020] [Indexed: 12/12/2022]
Abstract
Background Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes. Objective The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK. Patients and Methods Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. Results Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p < 0.001) was seen over the time period, and overall survival improved from 22 to 56 months (p < 0.001); however, morbidity increased from 54 to 68% (p = 0.004). Conclusions Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.
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Affiliation(s)
- S Michael Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Rhys Jones
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Sivesh Kathir Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Maziar Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Shajahan Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Arul Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Nick Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals, Newcastle-upon-Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle-upon-Tyne, UK.
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33
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Walsh KJ, Zhang H, Tan KS, Pedoto A, Desiderio DP, Fischer GW, Bains MS, Jones DR, Molena D, Amar D. Use of vasopressors during esophagectomy is not associated with increased risk of anastomotic leak. Dis Esophagus 2020; 34:5907947. [PMID: 32944749 PMCID: PMC8024447 DOI: 10.1093/dote/doaa090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
Vasopressor use during esophagectomy has been reported to increase the risk of postoperative anastomotic leak and associated morbidity. We sought to assess the association between vasopressor use and fluid (crystalloid and colloid) administration and anastomotic leak following open esophagectomy. Patients who underwent open Ivor Lewis esophagectomy were identified from a prospective institutional database. The primary outcome was postoperative anastomotic leak (any grade) and analyzed using logistic regression models. Postoperative anastomotic leak developed in 52 of 327 consecutive patients (16%) and was not significantly associated with vasopressor use or fluid administered in either univariable or multivariable analyses. Increasing body mass index was the only significant characteristic of both univariable (P = 0.004) and multivariable analyses associated with anastomotic leak (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = 0.007). Of the 52 patients that developed an anastomotic leak, 12 (23%) were grade 1, 21 (40%) were grade 2 and 19 (37%) were grade 3. In our cohort, only body mass index, and not intraoperative vasopressor use and fluid administration, was significantly associated with increased odds of postoperative anastomotic leak following open Ivor Lewis esophagectomy.
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Affiliation(s)
- Kevin J Walsh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Hao Zhang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessia Pedoto
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Dawn P Desiderio
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Manjit S Bains
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Amar
- Address correspondence to: David Amar, MD, Director of Thoracic Anesthesia, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M-304, New York, NY 10021, USA.
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34
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Quan YH, Han KN, Kim HK. Fluorescence Image-Based Evaluation of Gastric Tube Perfusion during Esophagogastrostomy. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:178-183. [PMID: 32793449 PMCID: PMC7409886 DOI: 10.5090/kjtcs.2020.53.4.178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 12/21/2022]
Abstract
During esophagectomy and esophagogastrostomy, the prediction of anastomotic leakage relies on the operating surgeon's tactile or visual diagnosis. Therefore, anastomotic leaks are relatively unpredictable, and new intraoperative evaluation methods or tools are essential. A fluorescence imaging system enables visualization over a wide region of interest, and provides intuitive information on perfusion intraoperatively. Surgeons can choose the best anastomotic site of the gastric tube based on fluorescence images in real time during surgery. This technology provides better surgical outcomes when used with an optimal injection dose and timing of indocyanine green.
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Affiliation(s)
- Yu Hua Quan
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Department of Biomedical Science, Korea University College of Medicine, Seoul, Korea
| | - Kook Nam Han
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Department of Biomedical Science, Korea University College of Medicine, Seoul, Korea
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35
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Barberio M, Felli E, Seyller E, Longo F, Chand M, Gockel I, Geny B, Swanström L, Marescaux J, Agnus V, Diana M. Quantitative fluorescence angiography versus hyperspectral imaging to assess bowel ischemia: A comparative study in enhanced reality. Surgery 2020; 168:178-184. [PMID: 32223983 DOI: 10.1016/j.surg.2020.02.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fluorescence-based enhanced reality is a software that provides quantitative fluorescence angiography by computing the fluorescence intensity time-to-peak after intravenous indocyanine green. Hyperspectral imaging is a contrast-free, optical imaging modality which measures tissue oxygenation. METHODS In 8 pigs, an ischemic bowel segment created by dividing the arcade branches was imaged using hyperspectral imaging and fluorescence-based enhanced reality. Tissue oxygenation values were acquired through a hyperspectral imaging system. Subsequently, fluorescence angiography was performed using a near-infrared laparoscopic camera after intravenous injection of 0.2 mg/kg of indocyanine green. The time-to-peak fluorescence signal was analyzed through a proprietary software to realize a perfusion map. This was overlaid onto real-time images to obtain fluorescence-based enhanced reality. Simultaneously, 9 adjacent regions of interest were selected and superimposed onto the real-time video, thereby obtaining hyperspectral-based enhanced reality. Fluorescence-based enhanced reality and hyperspectral-based enhanced reality were superimposed allowing a comparison of both imaging modalities. Local capillary lactate levels were sampled at the regions of interest. Two prediction models using the local capillary lactate levels were extrapolated based on both imaging systems. RESULTS For all regions of interest, the mean local capillary lactate levels were 4.67 ± 4.34 mmol/L, the mean tissue oxygenation was 45.9 ± 18.9%, and the mean time-to-peak was 10 ± 9.4 seconds. Pearson's test between fluorescence-based enhanced reality-time-to-peak and hyperspectral imaging-tissue oxygenation at the corresponding regions of interest gave an R = -0.66 (P < .0001). The hyperspectral imaging lactate prediction model proved more accurate than the fluorescence-based enhanced reality-based model (P < .0001). CONCLUSION Bowel perfusion was quantified using hyperspectral imaging and fluorescence angiography. Hyperspectral imaging yielded more accurate results than fluorescence angiography. Hyperspectral-based enhanced reality may prove to be a useful, contrast-free intraoperative tool to quantify bowel ischemia.
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Affiliation(s)
- Manuel Barberio
- IHU-Strasbourg Institute of Image-Guided Surgery, France; Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Germany; EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France.
| | - Eric Felli
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Emilie Seyller
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Fabio Longo
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Manish Chand
- Division of Surgery & Interventional Science, University College London, United Kingdom
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Germany
| | - Bernard Geny
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France
| | - Lee Swanström
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Jacques Marescaux
- IHU-Strasbourg Institute of Image-Guided Surgery, France; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
| | - Vincent Agnus
- IHU-Strasbourg Institute of Image-Guided Surgery, France
| | - Michele Diana
- IHU-Strasbourg Institute of Image-Guided Surgery, France; EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, France; Research Institute against Digestive Cancer (IRCAD), Strasbourg, France
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Adusumilli PS, Bikson M, Rizk NP, Rusch VW, Hristov B, Grosser R, Tan KS, Sarkaria IS, Huang J, Molena D, Jones DR, Bains MS. A prospective trial of intraoperative tissue oxygenation measurement and its association with anastomotic leak rate after Ivor Lewis esophagectomy. J Thorac Dis 2020; 12:1449-1459. [PMID: 32395282 PMCID: PMC7212129 DOI: 10.21037/jtd.2020.02.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Anastomotic leak following Ivor Lewis esophagectomy is associated with increased morbidity/mortality and decreased survival. Tissue oxygenation at the anastomotic site may influence anastomotic leak. Methods for establishing tissue oxygenation at the anastomotic site are lacking. Methods Over a 2-year study period, 185 Ivor Lewis esophagectomies were performed. Study participants underwent measurement of gastric conduit tissue oxygenation at the planned anastomotic site using the wireless pulse oximetry device. Associations between anastomotic leaks or strictures and tissue oxygenation levels were analyzed using Wilcoxon rank sum test or Fisher’s exact test. Results Among study participants (n=114), median gastric conduit tissue oxygenation level was 92% (range, 62–100%). There were 8 (7.0%) anastomotic leaks and 3 (2.6%) strictures. Analysis of tissue oxygenation as a continuous variable showed no difference in median tissue oxygenation in patients with and without leaks (98% and 92%; P=0.2) and stricture formation (89% and 92%; P=0.6). Analysis of tissue oxygenation as a dichotomous variable found no difference in anastomotic leak rates [7.5% (n=93) in >80% vs. 0% (n=20) in ≤80%; P=0.3]. There were no significant differences in leak rates in concurrent study nonparticipants. Conclusions No significant association was observed between intraoperative tissue oxygenation at the anastomotic site and subsequent anastomotic leak or stricture formation among patients undergoing Ivor Lewis esophagectomy.
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Affiliation(s)
- Prasad S Adusumilli
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Center for Cell Engineering, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, New York, NY, USA
| | - Nabil P Rizk
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Valerie W Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Boris Hristov
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rachel Grosser
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Inderpal S Sarkaria
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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37
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The Utility of Indocyanine Green Angiography in the Assessment of Perfusion of Gastric Conduit and Proximal Esophageal Stump Against Visual Assessment in Patients Undergoing Esophagectomy: a Prospective Study. Indian J Surg Oncol 2020; 11:684-691. [PMID: 33281408 DOI: 10.1007/s13193-020-01085-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/28/2020] [Indexed: 01/28/2023] Open
Abstract
Post esophagectomy anastomotic leakage is a crucial factor in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complication. This prospective study compares the utility of intraoperative indocyanine green (ICG) fluorescence angiography and visual assessment in assessing the vascularity of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy. Thirteen consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019 were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic-assisted esophagectomy. Reconstruction was done by gastric pull-up via posterior mediastinal route. All patients underwent assessment of perfusion of gastric conduit and proximal esophageal stump by ICG angiography and by visual assessment based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges. Visual assessment revealed the tip of the gastric conduit was dusky and ischemic in 11 patients, pink and well perfused in two. ICG fluorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, adequate in one, overall requiring revision in 12 cases. There was a discrepancy in one patient where visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit's tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and by ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 s (10 to 23 s). In all the cases, the pattern of blush was simultaneous, with the concurrent appearance of ICG blush in the gastric conduit and gastro-epiploic arcade. No anastomotic leaks were noted. Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in randomized trials.
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38
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[Hybrid esophagectomy with intraoperative hyperspectral imaging : Video article]. Chirurg 2020; 91:1-12. [PMID: 32067066 DOI: 10.1007/s00104-020-01139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The technique of hybrid esophagectomy with systematic 2‑field lymphadenectomy for esophageal cancer showed a significant reduction in postoperative morbidity in a recently published prospective randomized study. This video publication presents the abdominothoracic hybrid procedure with (i) laparoscopic gastrolysis and ischemic conditioning of the stomach and (ii) 2-stage transthoracic esophagectomy with gastric pull-up, intrathoracic gastric tube formation and anastomosis. Intraoperative hyperspectral imaging (HSI) during the thoracic part of the operation is used for identification of the ideally perfused anastomotic region.
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39
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Duprée A, von Kroge PH, Izbicki JR, Wipper SH, Mann O. [Fluorescence angiography for esophageal anastomoses : Perfusion evaluation of the gastric conduit with indocyanine green]. Chirurg 2019; 90:875-879. [PMID: 31471660 DOI: 10.1007/s00104-019-01021-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The incidence of esophageal cancer continues to increase. Despite increasing experience in esophageal surgery and perioperative management, anastomotic leakage remains a frequent and severe complication. OBJECTIVE The aim of this article is to demonstrate the current role of fluorescence angiography (FA) with indocyanine green (ICG) in the assessment of esophageal anastomoses. The main focus is on the evaluation of the perfusion situation. MATERIAL AND METHODS A systematic search was carried out in PubMed and Medline on FA and ICG, especially with respect to current subjective and objective interpretation approaches of FA against the background of own research. RESULTS The rate of anastomotic leakage remains high despite modern surgical procedures. Assessment of neoesophageal perfusion with FA can significantly reduce the rate of anastomotic leakage. At present, FA is mostly subjectively applied in small case studies. The study situation is heterogeneous. Randomized studies do not so far exist. CONCLUSION The use of FA with ICG is suitable for evaluation of perfusion of the gastric tube. The implementation is simple and can be standardized. Prospective, randomized trials and objective quantification are needed in the future in order to clarify the potential of the technique.
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Affiliation(s)
- A Duprée
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - P H von Kroge
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - J R Izbicki
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - S H Wipper
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herz- und Gefäßzentrum, Universitätsklinikum Hamburg Eppendorf, Hamburg, Deutschland
| | - O Mann
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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40
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Barberio M, Longo F, Fiorillo C, Seeliger B, Mascagni P, Agnus V, Lindner V, Geny B, Charles AL, Gockel I, Worreth M, Saadi A, Marescaux J, Diana M. HYPerspectral Enhanced Reality (HYPER): a physiology-based surgical guidance tool. Surg Endosc 2019; 34:1736-1744. [PMID: 31309313 DOI: 10.1007/s00464-019-06959-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/01/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND HSI is an optical technology allowing for a real-time, contrast-free snapshot of physiological tissue properties, including oxygenation. Hyperspectral imaging (HSI) has the potential to quantify the gastrointestinal perfusion intraoperatively. This experimental study evaluates the accuracy of HSI, in order to quantify bowel perfusion, and to obtain a superposition of the hyperspectral information onto real-time images. METHODS In 6 pigs, 4 ischemic bowel loops were created (A, B, C, D) and imaged at set time points (from 5 to 360 min). A commercially available HSI system provided pseudo-color maps of the perfusion status (StO2, Near-InfraRed perfusion) and the tissue water index. An ad hoc software was developed to superimpose HSI information onto the live video, creating the HYPerspectral-based Enhanced Reality (HYPER). Seven regions of interest (ROIs) were identified in each bowel loop according to StO2 ranges, i.e., vascular (VASC proximal and distal), marginal vascular (MV proximal and distal), marginal ischemic (MI proximal and distal), and ischemic (ISCH). Local capillary lactates (LCL), reactive oxygen species (ROS), and histopathology were measured at the ROIs. A machine-learning-based prediction algorithm of LCL, based on the HSI-StO2%, was trained in the 6 pigs and tested on 5 additional animals. RESULTS HSI parameters (StO2 and NIR) were congruent with LCL levels, ROS production, and histopathology damage scores at the ROIs discriminated by HYPER. The global mean error of LCL prediction was 1.18 ± 1.35 mmol/L. For StO2 values > 30%, the mean error was 0.3 ± 0.33. CONCLUSIONS HYPER imaging could precisely quantify the overtime perfusion changes in this bowel ischemia model.
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Affiliation(s)
- Manuel Barberio
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Fabio Longo
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Claudio Fiorillo
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Barbara Seeliger
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Pietro Mascagni
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Vincent Agnus
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
| | - Veronique Lindner
- Department of Pathology, University Hospital of Strasbourg, Strasbourg, France
| | - Bernard Geny
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Anne-Laure Charles
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Marc Worreth
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Alend Saadi
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland
| | - Jacques Marescaux
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France
- IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France
| | - Michele Diana
- IHU Strasbourg, Institute of Image-Guided Surgery, 1 Place de l'Hôpital, 67091, Strasbourg, France.
- IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.
- Department of General, Digestive, and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
- EA 3072, Fédération de Médecine Translationnelle de Strasbourg, Medical University of Strasbourg, Strasbourg, France.
- Department of Surgery, Pourtalès Neuchâtel Hospital, Neuchâtel, Switzerland.
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Estimation of microvascular perfusion after esophagectomy: a quantitative model of dynamic fluorescence imaging. Med Biol Eng Comput 2019; 57:1889-1900. [PMID: 31243624 PMCID: PMC6706368 DOI: 10.1007/s11517-019-01994-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 05/16/2019] [Indexed: 02/08/2023]
Abstract
Most common complications of esophagectomy stem from a perfusion deficiency of the gastric conduit at the anastomosis. Fluorescent tracer imaging allows intraoperative visualization of tissue perfusion. Quantitative assessment of fluorescence dynamics has the potential to identify perfusion deficiency. We developed a perfusion model to analyze the relation between fluorescence dynamics and perfusion deficiency. The model divides the gastric conduit into two well-perfused and two anastomosed sites. Hemodynamics and tracer transport were modeled. We analyzed the value of relative time-to-threshold (RTT) as a predictor of the relative remaining flow (RRF). Intensity thresholds for RTT of 20% to 50% of the maximum fluorescence intensity of the well-perfused site were tested. The relation between RTT and RRF at the anastomosed sites was evaluated over large variations of vascular conductance and volume. The ability of RTT to distinguish between sufficient and impaired perfusion was analyzed using c-statistics. We found that RTT was a valuable estimate for low RRF. The threshold of 20% of the maximum fluorescence intensity provided the best prediction of impaired perfusion on the two anastomosed sites (AUC = 0.89 and 0.86). The presented model showed that for low flows, relative time-to-threshold may be used to estimate perfusion deficiency.
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Okusanya O, Lu M, Luketich JD, Sarkaria IS. Intraoperative near infrared fluorescence imaging for the assessment of the gastric conduit. J Thorac Dis 2019; 11:S750-S754. [PMID: 31080654 DOI: 10.21037/jtd.2018.12.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Esophagectomy remains a mainstay of multi-modality therapy in the treatment of malignant disease, as well as selected benign conditions. Anastomotic and conduit complications remain the Achilles' heel of these operations, contributing to major morbidity and mortality. Adequate vascular perfusion of the gastric conduit is vital to avoid these complications, with surgeon observational assessment the mainstay of determining the vascular health of the gastric conduit. Rates of morbidity remain significant, and technologies aimed at better assessing relative tissue perfusion and ischemia are increasingly under investigation and utilized. One such technique is the use of intraoperative near-infrared fluorescence imaging to directly assess these parameters. The application of this technique has shown promise in perfusion assessment during esophagectomy, and potential reduction in anastomotic complications.
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Affiliation(s)
- Olugbenga Okusanya
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Lu
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical School, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Motz BM, Lorimer PD, Boselli D, Symanowski JT, Reames MK, Hill JS, Salo JC. Minimally Invasive Ivor Lewis Esophagectomy Without Patient Repositioning. J Gastrointest Surg 2019; 23:870-873. [PMID: 30623378 DOI: 10.1007/s11605-018-4063-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 11/21/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The standard technique for Ivor Lewis minimally invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure. TECHNIQUE We describe our technique for a one-stage hand-assisted minimally invasive esophagectomy that allows sequential access to the chest and abdomen within the same surgical field, eliminating the need for repositioning. The patient is positioned in a "corkscrew" configuration with the abdomen supine and the chest rotated to the left to allow access to the right chest. The abdomen and chest are prepped into a single operative field. This technique allows sequential access to the abdomen for gastric mobilization, chest for division of the esophagus, abdomen for construction of the gastric conduit, and chest for intrathoracic anastomosis. CONCLUSION This approach enables extracorporeal construction of the conduit, which helps ensure a clear distal margin on the specimen and facilitates conduit length by placing the stomach on stretch during stapling.
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Affiliation(s)
- Benjamin M Motz
- Department of Surgery, Division of Surgical Oncology, Carolinas Medical Center, Levine Cancer Institute, 1021 Morehead Medical Drive #6100, Charlotte, NC, 28204, USA
| | - Patrick D Lorimer
- Department of Surgery, Division of Surgical Oncology, Carolinas Medical Center, Levine Cancer Institute, 1021 Morehead Medical Drive #6100, Charlotte, NC, 28204, USA
| | - Danielle Boselli
- Department of Biostatistics and Informatics, Levine Cancer Institute, Atrium Health, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - James T Symanowski
- Department of Biostatistics and Informatics, Levine Cancer Institute, Atrium Health, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Mark K Reames
- Carolinas Medical Center, Sanger Heart and Vascular Institute, 1000 Blythe Blvd., Charlotte, NC, 28203, USA
| | - Joshua S Hill
- Department of Surgery, Division of Surgical Oncology, Carolinas Medical Center, Levine Cancer Institute, 1021 Morehead Medical Drive #6100, Charlotte, NC, 28204, USA
| | - Jonathan C Salo
- Department of Surgery, Division of Surgical Oncology, Carolinas Medical Center, Levine Cancer Institute, 1021 Morehead Medical Drive #6100, Charlotte, NC, 28204, USA.
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Klevebro F, Boshier PR, Low DE. Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy. J Thorac Dis 2019; 11:S692-S701. [PMID: 31080646 PMCID: PMC6503292 DOI: 10.21037/jtd.2018.11.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022]
Abstract
Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.
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Affiliation(s)
- Fredrik Klevebro
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Piers R Boshier
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, USA
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Slooter MD, Eshuis WJ, Cuesta MA, Gisbertz SS, van Berge Henegouwen MI. Fluorescent imaging using indocyanine green during esophagectomy to prevent surgical morbidity: a systematic review and meta-analysis. J Thorac Dis 2019; 11:S755-S765. [PMID: 31080655 DOI: 10.21037/jtd.2019.01.30] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Fluorescent imaging using indocyanine green (ICG) is an emerging technique that aids the surgeon with intraoperative decision making during upper gastrointestinal cancer surgery. In this systematic review we aim to provide an overview of current practice of fluorescence imaging using ICG during esophagectomy, and to show how this technology can prevent surgical morbidity, such as anastomotic leakage, graft necrosis and chylothorax. Methods The PRISMA standard for systematic reviews was used. The PubMed and Embase database were searched to identify articles matching our systematic literature search. Two authors screened all included articles for eligibility. Risk of bias was assessed for all included articles. Results A total of 25 articles were included in this review: 22 articles on perfusion assessment, and three on the detection of chyle fistula. Five out of 22 articles concerning perfusion assessment evaluated fluorescence signals in quantitative values. In 20 articles the pooled incidence of anastomotic leakage and graft necrosis in the ICG group was 11.10% (95% CI: 8.06-15.09%) and in eight studies the pooled change in management rate was 24.55% (95% CI: 19.16-30.88%). After change in management, the pooled incidence of anastomotic leakage and graft necrosis was 14.08% (95% CI: 6.55-27.70%). A meta-analysis showed that less anastomotic leakages and graft necrosis occur in the ICG group (OR 0.30, 95% CI: 0.14-0.63). Three case-reports (N=3) were identified regarding chyle fistula detection, and ICG lymphography detected the thoracic duct in all cases and the chyle fistula in one case. Conclusions Fluorescence imaging using ICG is a promising and safe technology to reduce surgical morbidity after esophagectomy with continuity restoration. ICG fluorescence angiography showed a reduction in anastomotic leakage and graft necrosis. Future studies are needed to demonstrate the feasibility of ICG lymphography for chyle fistula detection.
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Affiliation(s)
- Maxime D Slooter
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Miguel A Cuesta
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Van Daele E, Van Nieuwenhove Y, Ceelen W, Vanhove C, Braeckman BP, Hoorens A, Van Limmen J, Varin O, Van de Putte D, Willaert W, Pattyn P. Near-infrared fluorescence guided esophageal reconstructive surgery: A systematic review. World J Gastrointest Oncol 2019; 11:250-263. [PMID: 30918597 PMCID: PMC6425328 DOI: 10.4251/wjgo.v11.i3.250] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/21/2019] [Accepted: 01/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND After an esophagectomy, the stomach is most commonly used to restore continuity of the upper gastrointestinal tract. These esophago-gastric anastomoses are prone to serious complications such as leakage associated with high morbidity and mortality. Graft perfusion is considered to be an important predictor for anastomotic integrity. Based on the current literature we believe Indocyanine green fluorescence angiography (ICGA) is an easy assessment tool for gastric tube (GT) perfusion, and it might predict anastomotic leakage (AL).
AIM To evaluate feasibility and effectiveness of ICGA in GT perfusion assessment and as a predictor of AL.
METHODS This study was designed according to the PRISMA guidelines and registered in the PROSPERO database. PubMed and EMBASE were independently searched by 2 reviewers for studies presenting data on intraoperative ICGA GT perfusion assessment during esophago-gastric reconstruction after esophagectomy. Relevant outcomes such as feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications, were collected by 2 independent researchers. The quality of the included articles was assessed based on the Methodological Index for Non-Randomized Studies. The 19 included studies presented data on 1192 esophagectomy patients, in 758 patients ICGA was used perioperative to guide esophageal reconstruction.
RESULTS The 19 included studies for qualitative analyses all described ICGA as a safe and easy method to evaluate gastric graft perfusion. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (P < 0.001). When poorly perfused cases are excluded from the analyses, the difference in AL was even larger (AL well-perfused group 6.3% vs control group 20.5%, P < 0.001). The AL rate in the group with an altered surgical plan based on the ICG image was 6.5%, similar to the well perfused group (6.3%) and significantly less than the poorly perfused group (47.8%) (P < 0.001), suggesting that the technique is able to identify and alter a potential bad outcome.
CONCLUSION ICGA is a safe, feasible and promising method for perfusion assessment. The lower AL rate in the well perfused group suggest that a good fluorescent signal predicts a good outcome.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Christian Vanhove
- Department of Electronics and information systems, Ghent University, Ghent B-9000, Belgium
| | | | - Anne Hoorens
- Department of Pathology, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Jurgen Van Limmen
- Department of Anaesthesiology, Ghent University Hospital/ Ghent University, Ghent B-9000, Belgium
| | - Oswald Varin
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Dirk Van de Putte
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Wouter Willaert
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital/Ghent University, Ghent B-9000, Belgium
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Okusanya OT, Hess NR, Luketich JD, Sarkaria IS. Infrared intraoperative fluorescence imaging using indocyanine green in thoracic surgery. Eur J Cardiothorac Surg 2019; 53:512-518. [PMID: 29029002 DOI: 10.1093/ejcts/ezx352] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/30/2017] [Indexed: 01/21/2023] Open
Abstract
Thoracic surgery faces many unique challenges that require innovative solutions. The increase in utilization of minimally invasive practices, poor overall cancer survival and significant morbidity of key operations remain key obstacles to overcome. Intraoperative fluorescence imaging is a process by which fluorescent dyes and imaging systems are used as adjuncts for surgeons in the operating room. Other surgical subspecialists have shown that intraoperative fluorescence imaging can be applied as a practical adjunct to their practices. Thoracic surgeons over the last 15 years have also used intraoperative fluorescence imaging for sentinel lymph node mapping, lung mapping, oesophageal conduit vascular perfusion and lung nodule identification. This review describes some of the key studies that demonstrate the applications of intraoperative near-infrared fluorescence imaging.
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Affiliation(s)
- Olugbenga T Okusanya
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Quantitative Assessment of Blood Flow in the Gastric Conduit With Thermal Imaging for Esophageal Reconstruction. Ann Surg 2018; 271:1087-1094. [DOI: 10.1097/sla.0000000000003169] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Indocyanine green for the prevention of anastomotic leaks following esophagectomy: a meta-analysis. Surg Endosc 2018; 33:384-394. [PMID: 30386983 DOI: 10.1007/s00464-018-6503-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Intraoperative evaluation with fluorescence angiography using indocyanine green (ICG) offers a dynamic assessment of gastric conduit perfusion and can guide anastomotic site selection during an esophagectomy. This study aims to evaluate the predictive value of ICG for the prevention of anastomotic leak following esophagectomy. METHODS A comprehensive search of electronic databases using the search terms "indocyanine/fluorescence" AND esophagectomy was completed to include all English articles published between January 1946 and 2018. Articles were selected by two independent reviewers. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. RESULTS Seventeen studies were included for meta-analysis after screening and exclusions. The pooled anastomotic leak rate when ICG was used was found to be 10%. When limited to studies without intraoperative modifications, the pooled sensitivity, specificity, and diagnostic odds ratio were 0.78 (95% CI 0.52-0.94; p = 0.089), 0.74 (95% CI 0.61-0.84; p = 0.012), and 8.94 (95% CI 1.24-64.21; p = 0.184), respectively. Six trials compared ICG with an intraoperative intervention to improve perfusion to no ICG. ICG with intervention was found to have a risk reduction of 69% (OR 0.31, 95% CI 0.15-0.63). CONCLUSIONS In non-randomized trials, the use of ICG as an intraoperative tool for visualizing microvascular perfusion and conduit site selection to decrease anastomotic leaks is promising. However, poor data quality and heterogeneity in reported variables limits generalizability of findings. Randomized, multi-center trials are needed to account for independent risk factors for leak rates and to better elucidate the impact of ICG in predicting and preventing anastomotic leaks.
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50
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Abstract
Intraoperative fluorescence imaging (FI) with indocyanine green has several potential uses during esophagectomy. Intravascular injection for enhancing the visualization of conduit vascularity and assessing macro and microperfusion has the most literature support and may help reduce anastomotic leaks. Peritumoral injection has been reported for use in identifying sentinel nodes during lymphadenectomy and intralymphatic injection may be used to help preserve or ligate the thoracic duct. The authors' own technique of FI for conduit assessment is described. They routinely use this strategy to guide anastomosis placement and reduce leaks.
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Affiliation(s)
- Simon R. Turner
- Division of Thoracic Surgery, University of Alberta, Edmonton, Canada 416 CSC, 10240 Kingsway Ave, Edmonton, AB, T5H 3V9,
| | - Daniela R. Molena
- Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY 1275 York Ave, New York, NY, 10065,
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