Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery

Evaluation of anastomotic blood supply during digestive tract reconstruction with the use of the oxygen saturation index: A pooling up analysis

PURPOSE

Anastomotic leakage (AL) is one of the most serious clinical complications in digestive tract reconstruction (DTR) surgery, and it is currently hypothesized that this may be related to insufficient anastomotic blood supply. Thus, Therefore, we aimed to assess the ability of tissue oxygen saturation(StO2) as a measure to evaluate anastomotic blood supply.

METHODS

A comprehensive literature search was performed using Embase, PubMed and Cochrane Library. StO2 was used as an evaluation index of anastomotic blood supply after DTR to analyze the potential association between this index and the occurrence of AL in the postoperative period.

RESULTS

A total of eleven articles involving 867 participants were included in this systematic review and meta-analysis. After pooling the standardized mean difference (SMD) and 95% confidence intervals (Cls), low StO2 was found to be an independent risk factor for AL (P < 0.00001; 95%CI: 1.02 [0.53-1.51]). The mean StO2 in the AL group (62.3%) was significantly lower than that in the non-AL group (74.3%); AL incidence increased with the reduction of StO2 to a certain value to 201.8% and 338.1% respectively.

CONCLUSION

Oxygen saturation index can be utilized in DTR to accurately and quantitatively evaluate the anastomotic blood supply to reduce the probability of postoperative AL.

Real-Time Navigation in Liver Surgery Through Indocyanine Green Fluorescence: An Updated Analysis of Worldwide Protocols and Applications

BACKGROUND

Indocyanine green (ICG) fluorescence has seen extensive application across medical and surgical fields, praised for its real-time navigation capabilities and low toxicity. Initially employed to assess liver function, ICG fluorescence is now integral to liver surgery, aiding in tumor detection, liver segmentation, and the visualization of bile leaks. This study reviews current protocols and ICG fluorescence applications in liver surgery, with a focus on optimizing timing and dosage based on clinical indications.

METHODS

Following PRISMA guidelines, we systematically reviewed the literature up to 27 January 2024, using PubMed and Medline to identify studies on ICG fluorescence used in liver surgery. A systematic review was performed to evaluate dosage and timing protocols for ICG administration.

RESULTS

Of 1093 initial articles, 140 studies, covering a total of 3739 patients, were included. The studies primarily addressed tumor detection (40%), liver segmentation (34.6%), and both (21.4%). The most common ICG fluorescence dose for tumor detection was 0.5 mg/kg, with administration occurring from days to weeks pre-surgery. Various near-infrared (NIR) camera systems were utilized, with the PINPOINT system most frequently cited. Tumor detection rates averaged 87.4%, with a 10.5% false-positive rate. Additional applications include the detection of bile leaks, lymph nodes, and vascular and biliary structures.

CONCLUSIONS

ICG fluorescence imaging has emerged as a valuable tool in liver surgery, enhancing real-time navigation and improving clinical outcomes. Standardizing protocols could further enhance ICG fluorescence efficacy and reliability, benefitting patient care in hepatic surgeries.

Practical Guidelines for the Use of Indocyanine Green in Different Branches of Pediatric Surgery: A Polish Nationwide Multi-Center Retrospective Cohort Study

Background and Aim

Pediatric surgery requires high precision and safety due to children's unique anatomy and physiology. Innovations that enhance surgical precision, reduce operative time, and improve postoperative outcomes are invaluable. Indocyanine green (ICG), a near-infrared fluorescent dye, has received significant attention for its potential to address these needs. The study aimed to describe applications of ICH in pediatric surgery in Poland, provide evidence to support integration of ICG into pediatric surgical practice and evaluate the safety and feasibility of ICG.

Methods

Data were collected from the medical records of 136 patients undergoing surgical treatment in four leading pediatric surgical clinical centers in Poland. There are four main groups of surgical procedures: oncological, gastrointestinal, urological and lymphatic. Calculations were performed using Statistica 13 by TIBCO and PQStat v. 1.8.6.120 by PQStat Software. Additionally, descriptive statistics were performed.

Results

The efficacy and safety of ICG were confirmed in the entire study group. No complications were reported with the use of the indocyanine green. Exhaustive descriptive statistics presented key information on the use of ICG for each of the studied groups.

Conclusions

The study validates the efficacy and safety of ICG fluorescence imaging in pediatric surgery. By enhancing surgical precision and improving postoperative outcomes, ICG represents a significant advancement in pediatric surgical care. The establishment of standardized protocols and the emphasis on specialized training will be key to maximizing the benefits of ICG.

Colorectal surgeons' perspectives on the efficacy of intraoperative bowel perfusion technology with a focus on indocyanine green fluorescence angiography

BACKGROUND

Level one evidence supports indocyanine green fluorescence angiography (ICGFA) use reducing anastomotic leak rates in colorectal surgery. We surveyed surgeons exploring perceptions and factors affecting its use in daily practice and adoption as routine standard of care.

METHODS

Validated electronic survey distributed via the Irish Association of Coloproctology, Royal College of Surgeons in Ireland, European Society of Surgical Oncology, European Association for Endoscopic Surgery, Milan Colorectal Congress and social media.

RESULTS

200 colorectal surgeons (143 consultants) responded. 147 (73.5%) surgeons already use ICGFA, with 90 (61.2%) using it routinely and 69 (46.9%) having a concomitant research interest. Strong clinical evidence base (83.5%) and protocol standardisation (78%) were overall rated most important for bowel perfusion technology with a majority of surgeons rating lack of standardisation and inter-user variability as challenges (similar between consultants and non-consultants). Lack of training and staff, reliability concerns and data security were perceived as significant barriers by selective users compared to non-users, and cost and operating time were perceived as significant barriers by selective users compared to routine users. Most surgeons (41.5%) ideated a number needed to treat (NNT) between 20 and 40 acceptable to advocate routine ICGFA use with 28% requiring a NNT < 20. Most surgeons (38.5%) indicate a per case cost savings of €250-500 supports routine use with 17% advocating it > €750.

CONCLUSIONS

With now a strong evidence base regarding clinical benefit, the survey respondents articulate remaining challenges for ICGFA as standard of care. Levels of expected benefit are largely in keeping with its reported performance.

Review of Clinically Assessed Molecular Fluorophores for Intraoperative Image Guided Surgery

The term "fluorescence" was first proposed nearly two centuries ago, yet its application in clinical medicine has a relatively brief history coming to the fore in the past decade. Nowadays, as fluorescence is gradually expanding into more medical applications, fluorescence image-guided surgery has become the new arena for this technology. It allows surgical teams to real-time visualize target tissues or anatomies intraoperatively to increase the precision of resection or preserve vital structures during open or laparoscopic surgeries. In this review, we introduce the concept of near-infrared fluorescence guided surgery, discuss the recent and ongoing clinical trials of molecular fluorophores (indocyanine green, 5-aminolevulinic acid, methylene blue, IR-dye 800CW, pafolacianine) and their surgical goals, highlight key chemical and medical factors for imaging agent optimization, deliberate challenges and potential advantages, and propose a framework for integrating this technology into routine surgical care in the near future. The notable clinical achievements of these fluorophores over the past decade strongly indicates that the future of fluorescence in surgery is bright with many more patient benefits to come.

Understanding Surgeons' Reluctance to Adopt Intraoperative Coronary Graft Verification Procedures: A Literature Review Combined to AI-Driven Insights Under Human Supervision

Background: Intraoperative graft verification in coronary surgery is accepted worldwidand equally discussed. In spite of multiple sources of evidence published up to now in favor of clinical benefits following the use of the procedure, there is a persistent skepticism in adopting the available technologies. The object of the present review is to analyze the reluctance of surgeons toward the adoption of assessment methods. Materials and Method: A thorough literature review was carried out on Google Scholar based on the results obtained from AI's answer to the question about the reasons for that reluctance. We took advantage of using ChatGPT-4 since the research based on PubMed Central alone was not able to return a detailed response, maybe because the reasons for the reluctance are veiled in the text of the published papers. Through the items suggested by AI and taken from the literature, we deepened the research, pointing attention to the issues published so far about the various technologies. Results: There are many convincing pieces of evidence about the utility of intraoperative graft control in coronary surgery, involving improved clinical outcome, efficacy and safety, and social cost saving. The opinion that arose through this analysis is that, beyond the objective difficulties in utilizing some technologies and the equally objective limitations of an economic and organizational nature, the reluctance is the result of a real unwillingness based on the various implications that the discovery of the technical error entails. Conclusions: This negative attitude, in light of the convincing scientific and clinical evidence published up to now, appears to overwhelm the benefits for patients.

[Modern approaches and technologies to prevent anastomotic leakage in the gastrointestinal tract]

The healing of gastrointestinal anastomoses is a complex biological process influenced by numerous factors. Various strategies to support healing and prevent anastomotic leakage (AL) exist, encompassing preoperative, intraoperative and postoperative measures. Preoperative interventions aim to optimize the patient and the tissue environment, particularly the gut microbiome. Intraoperative measures are technical in nature and include the choice of surgical access, the anastomotic technique and anastomotic reinforcement. Various procedures of the intraoperative diagnostics enable identification of such anastomoses requiring additional protective measures. Recently, indocyanine green (ICG) fluoroscopy has become established for evaluation of tissue perfusion, while newer techniques such as spectral microscopy offer promising possibilities. Postoperative diagnostic methods aim to identify potential AL as early as possible to enable initiation of therapeutic steps even before the onset of symptoms. These procedures range from various imaging techniques to innovative bioresorbable, pH-sensitive implants for early AL detection. Due to the multifactorial genesis of AL and the diverse technical possibilities, no single method will become established for prevention of AL. Instead, a combination of measures will ultimately lead to optimal anastomotic healing. The use of artificial intelligence and analyses based on the data promises a better interpretation of the vast amount of data and therefore to be able to provide general recommendations.

The Role of ICG During the SADI-S Procedure

Indocyanine green (ICG) is a nontoxic, fluorescent iodide dye with rapid hepatic clearance that has been used in medical applications since the mid-1950s. In abdominal surgery, ICG can be used to identify anatomical structures such as the biliary tract, urinary tract, blood vessels, tissue perfusion on different organs, or anastomosis in the digestive system. The application of ICG during bariatric surgery may be useful in primary and revisional procedures at different steps of the surgery. The purpose of this study is to examine the role of indocyanine green during the SADI-S procedure and to highlight the key aspects of this procedure. We present a case series of 22 patients with morbid obesity who underwent a multidisciplinary evaluation and were selected for the SADI-S procedure via a laparoscopic approach. The ICG dose and timing were as recommended in the International Society for Fluorescence Guided Surgery guidelines. For arteriography, 3 ml (7.5 mg) was used, and the detection time was 30-60 s after intravenous administration. For visualization of the common bile duct, we used 1 ml (2.5 mg) applied intravenously at least 45 min before the procedure. For the leak test, a dilution of 1 ml (2.5 mg) of ICG + 5 ml of methylene blue in 100 cc of sterile water, which was prepared just before the test, was used, and the mixture was passed through an orogastric tube. We expose the surgical steps in which ICG can improve outcomes or prevent complications when performing the SADI-S procedure. Key Points • The role of ICG during SADI-S is described. • The step-by-step results of ICG during the SADI-S procedure are highlighted. • ICG was shown to be safe and useful during bariatric surgery in morbidly obese patients.

The use of near-infrared angiography in evaluating bowel anastomosis during a gynecologic oncology surgery

Reducing anastomotic leak rates after bowel resection is a priority among patients undergoing gynecologic oncology surgery. While near-infrared (NIR) angiography has been investigated in the colorectal literature, more recent work has demonstrated promising results when used in gynecologic cancer surgery. It has been repeatedly shown to be a safe intervention that can offer real time assessment of bowel perfusion, offering the surgeon the opportunity to act on the results in the hopes of decreasing the risk of complications.

Blood perfusion assessment by near-infrared fluorescence angiography of epiploic appendages in prevention of anastomotic leakage after laparoscopic intersphincteric resection for ultra-low rectal cancer: a case-matched study

BACKGROUND

The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated.

AIM

Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR.

MATERIAL AND METHODS

A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL).

RESULTS

After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029).

CONCLUSIONS

Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.

How to objectively evaluate the impact of image-guided surgery technologies

PURPOSE

This manuscript aims to provide a better understanding of methods and techniques with which one can better quantify the impact of image-guided surgical technologies.

METHODS

A literature review was conducted with regard to economic and technical methods of medical device evaluation in various countries. Attention was focused on applications related to image-guided interventions that have enabled procedures to be performed in a minimally invasive manner, produced superior clinical outcomes, or have become standard of care.

RESULTS

The review provides examples of successful implementations and adoption of image-guided surgical techniques, mostly in the field of neurosurgery. Failures as well as newly developed technologies still undergoing cost-efficacy analysis are discussed.

CONCLUSION

The field of image-guided surgery has evolved from solely using preoperative images to utilizing highly specific tools and software to provide more information to the interventionalist in real time. While deformations in soft tissue often preclude the use of such instruments outside of neurosurgery, recent developments in optical and radioactive guidance have enabled surgeons to better account for organ motion and provide feedback to the surgeon as tissue is cut. These technologies are currently undergoing value assessments in many countries and hold promise to improve outcomes for patients, surgeons, care teams, payors, and society in general.

Clinical and computational development of a patient-calibrated ICGFA bowel transection recommender

INTRODUCTION

Intraoperative indocyanine green fluorescence angiography (ICGFA) aims to reduce colorectal anastomotic complications. However, signal interpretation is inconsistent and confounded by patient physiology and system behaviours. Here, we demonstrate a proof of concept of a novel clinical and computational method for patient calibrated quantitative ICGFA (QICGFA) bowel transection recommendation.

METHODS

Patients undergoing elective colorectal resection had colonic ICGFA both immediately after operative commencement prior to any dissection and again, as usual, just before anastomotic construction. Video recordings of both ICGFA acquisitions were blindly quantified post hoc across selected colonic regions of interest (ROIs) using tracking-quantification software and computationally compared with satisfactory perfusion assumed in second time-point ROIs, demonstrating 85% agreement with baseline ICGFA. ROI quantification outputs detailing projected perfusion sufficiency-insufficiency zones were compared to the actual surgeon-selected transection/anastomotic construction site for left/right-sided resections, respectively. Anastomotic outcomes were recorded, and tissue lactate was also measured in the devascularised colonic segment in a subgroup of patients. The novel perfusion zone projections were developed as full-screen recommendations via overlay heatmaps.

RESULTS

No patient suffered intra- or early postoperative anastomotic complications. Following computational development (n = 14) the software recommended zone (ROI) contained the expert surgical site of transection in almost all cases (Jaccard similarity index 0.91) of the nine patient validation series. Previously published ICGFA time-series milestone descriptors correlated moderately well, but lactate measurements did not. High resolution augmented reality heatmaps presenting recommendations from all pixels of the bowel ICGFA were generated for all cases.

CONCLUSIONS

By benchmarking to the patient's own baseline perfusion, this novel QICGFA method could allow the deployment of algorithmic personalised NIR bowel transection point recommendation in a way fitting existing clinical workflow.

Indocyanine green fluorescence angiography in colorectal surgery: A retrospective case-control analysis in Mexico

INTRODUCTION AND AIMS

An anastomotic leak is one of the most dreaded complications in colorectal surgery because it increases postoperative morbidity and mortality. The aim of the present study was to identify whether indocyanine green fluorescence angiography (ICGFA) reduced the anastomotic dehiscence rate in colorectal surgery.

MATERIAL AND METHODS

A retrospective study on patients that underwent colorectal surgery with colonic resection or low anterior resection and primary anastomosis, within the time frame of January 2019 and September 2021, was conducted. The patients were divided into the case group, in which ICGFA was performed for the intraoperative evaluation of blood perfusion at the anastomosis site, and the control group, in which ICGFA was not utilized.

RESULTS

A total of 168 medical records were reviewed, resulting in 83 cases and 85 controls. Inadequate perfusion that required changing the surgical site of the anastomosis was identified in 4.8% of the case group (n = 4). A trend toward reducing the leak rate with ICGFA was identified (6% [n = 5] in the cases vs 7.1% in the controls [n = 6] [p = 0.999]). The patients that underwent anastomosis site change due to inadequate perfusion had a 0% leak rate.

CONCLUSIONS

ICGFA as a method to evaluate intraoperative blood perfusion showed a trend toward reducing the incidence of anastomotic leak in colorectal surgery.

Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials

AIM

Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery.

METHOD

PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool.

RESULTS

Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG.

CONCLUSION

Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.

Impact of standardising indocyanine green fluorescence angiography technique for visual and quantitative interpretation on interuser variability in colorectal surgery

AIM/BACKGROUND

Intra-operative colonic perfusion assessment via indocyanine green fluorescence angiography (ICGFA) aims to address malperfusion-related anastomotic complications; however, its interpretation suffers interuser variability (IUV), especially early in ICGFA experience. This work assesses the impact of a protocol developed for both operator-based judgement and computational development on interpretation consistency, focusing on senior surgeons yet to start using ICGFA.

METHODS

Experienced and junior gastrointestinal surgeons were invited to complete an ICGFA-experience questionnaire. They subsequently interpreted nine operative ICGFA videos regarding perfusion sufficiency of a surgically prepared distal colon during laparoscopic anterior resection by indicating their preferred site of proximal transection using an online annotation platform (mindstamp.com). Six ICGFA videos had been prepared with a clinical standardisation protocol controlling camera and patient positioning of which three each had monochrome near infrared (NIR) and overlay display. Three others were non-standardised controls with synchronous NIR and overlay picture-in-picture display. Differences in transection level between different cohorts were assessed for intraclass correlation coefficient (ICC) via ImageJ and IBM SPSS.

RESULTS

58 clinicians (12 ICGFA experts, 46 ICGFA inexperienced of whom 23 were either finished or within one year of finishing training and 23 were junior trainees) participated as per power calculations. 63% felt that ICGFA should be routinely deployed with 57% believing interpretative competence requires 11-50 cases. Transection level concordance was generally good (ICC = 0.869) across all videos and levels of expertise (0.833-0.915). However, poor agreement was evident with the standardised protocol videos for overlay presentation (0.208-0.345). Similarly, poor agreement was seen for the monochrome display (0.392-0.517), except for those who were trained but ICG inexperienced (0.877) although even here agreement was less than with unstandardised videos (0.943).

CONCLUSION

Colorectal ICGFA acquisition and display standardisation impacts IUV with this specific protocol tending to diminish surgeon interpretation consistency. ICGFA video recording for computational development may require dedicated protocols.

Intraoperative assessment of anastomotic blood supply using indocyanine green fluorescence imaging following esophagojejunostomy or esophagogastrostomy for gastric cancer

OBJECTIVE

This retrospective study aimed to evaluate the feasibility and safety of intraoperative assessment of anastomotic blood supply in patients undergoing esophagojejunostomy or esophagogastrostomy for gastric cancer using Indocyanine Green Fluorescence Imaging (IGFI).

MATERIALS AND METHODS

From January 2019 to October 2021, we conducted a retrospective analysis of patients who had undergone laparoscopic gastrectomy for the treatment of gastric cancer. The patients were consecutively enrolled and categorized into two study groups: the Indocyanine Green Fluorescence Imaging (IGFI) group consisting of 86 patients, and the control group comprising 92 patients. In the IGFI group, intravenous administration of Indocyanine Green (ICG) was performed, and we utilized a fluorescence camera system to assess anastomotic blood supply both before and after the anastomosis.

RESULTS

The demographic characteristics of patients in both groups were found to be comparable. In the IGFI group, the mean time to observe perfusion fluorescence was 26.3 ± 12.0 seconds post-ICG injection, and six patients needed to select a more proximal resection point due to insufficient fluorescence at their initial site of choice. Notably, the IGFI group exhibited a lower incidence of postoperative anastomotic leakage, with no significant disparities observed in terms of pathological outcomes, postoperative recovery, or other postoperative complication rates when compared to the control group (p > 0.05).

CONCLUSION

This study underscores the potential of IGFI as a dependable and pragmatic tool for the assessment of anastomotic blood supply following esophagojejunostomy or esophagogastrostomy for gastric cancer. The use of IGFI may potentially reduce the occurrence of postoperative anastomotic leakage.

Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green

Indocyanine green (ICG) is a water-soluble fluorescent dye that is minimally toxic and widely used in gastrointestinal surgery. ICG facilitates anatomical identification of structures (e.g., ureters), assessment of lymph nodes, biliary mapping, organ perfusion and anastomosis assessment, and aids in determining the adequacy of oncological margins. In addition, ICG can be conjugated to artificially created antibodies for tumour markers, such as carcinoembryonic antigen for colorectal, breast, lung, and gastric cancer, prostate-specific antigen for prostate cancer, and cancer antigen 125 for ovarian cancer. Although ICG has shown promising results, the optimization of patient factors, dye factors, equipment, and the method of assessing fluorescence intensity could further enhance its utility. This review summarizes the clinical application of ICG in gastrointestinal surgery and discusses the emergence of novel dyes such as ZW-800 and VM678 that have demonstrated appropriate pharmacokinetic properties and improved target-to-background ratios in animal studies. With the emergence of robotic technology and the increasing reporting of ICG utility, a comprehensive review of clinical application of ICG in gastrointestinal surgery is timely and this review serves that aim.

Indocyanine Green Fluorescence Guided Surgery in Colorectal Surgery

BACKGROUND

Indocyanine green (ICG) imaging has been increasingly used for intraoperative guidance in colorectal surgery over the past decade. The aim of this study was to review and organize, according to different type of use, all available literature on ICG guided colorectal surgery and highlight areas in need of further research and discuss future perspectives.

METHODS

PubMed, Scopus, and Google Scholar databases were searched systematically through November 2022 for all available studies on fluorescence-guided surgery in colorectal surgery.

RESULTS

Available studies described ICG use in colorectal surgery for perfusion assessment, ureteral and urethral assessment, lymphatic mapping, and hepatic and peritoneal metastases assessment. Although the level of evidence is low, results are promising, especially in the role of ICG in reducing anastomotic leaks.

CONCLUSIONS

ICG imaging is a safe and relatively cheap imaging modality in colorectal surgery, especially for perfusion assessment. Work is underway regarding its use in lymphatic mapping, ureter identification, and the assessment of intraperitoneal metastatic disease.

The Role of Indocyanine Green Fluorescence in Rectal Cancer Robotic Surgery: A Narrative Review

Background: In rectal cancer surgery, anastomotic leakage (AL) remains the most feared complication, with a frequency of up to 30% in non-high-volume centers. The preservation of proper vascularization is a key factor for successful anastomosis. The use of fluorescence with indocyanine green (ICG) as an intraoperative method to verify optimal perfusion is becoming an interesting tool in rectal surgery. Today, robotic surgery, together with the use of the intraoperative evaluation of the perfusion with ICG, could be a real strategy to deal with AL, allowing for a more delicate and less traumatic surgical technique. This strategy may allow for an extremely accurate surgery, and for optimal control of the proper vascularization of the rectum. Methods: The purpose of this descriptive review is to analyze the impact of fluorescence and robotic surgery on short-term surgical outcomes for rectal cancer. Results: We performed a systematic literature search using the PubMed, Embase and Cochrane library databases. The primary endpoints were to evaluate the application of ICG fluorescence in robotic rectal surgery and the rate of anastomotic leakage when using these technological implementations. The secondary endpoints were to evaluate the dosage of ICG and the timing of application by different surgeons. Conclusions: ICG fluorescence is an inexpensive and quick method to assess bowel perfusion, providing immediate feedback to the surgeon, even if its role has not been proven. A quantitative system must be systematically introduced to minimize the subjectiveness of the visualized image.