Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery

A novel imaging technology to assess tissue oxygen saturation and its correlation with indocyanine green in the gastric conduit during thoracic esophagectomy

BACKGROUND

Anastomotic leakage in esophagectomy is a serious complication, and assessing blood perfusion in the conduit can help minimize this risk. Indocyanine green is the most widely used method to assess tissue blood flow; however, this technique has disadvantages. Evaluating tissue oxygen saturation in the gastric conduit during thoracic esophagectomy compared with indocyanine green blood perfusion assessment addresses these disadvantages and can be performed easily and repeatedly.

METHODS

This was a prospective study of patients with esophageal cancer who underwent thoracic esophagectomy. Intraoperative tissue oxygen saturation and indocyanine green measurements were obtained to determine the anastomotic site and to compare the correlation between the 2 methods. Tissue oxygen saturation and indocyanine green values were obtained at the tip of the gastric conduit, the demarcation line indicating visible perfusion, and the end of the right gastroepiploic artery.

RESULTS

Fifty-seven patients were enrolled in this study; 3 developed anastomotic leakage, and all 3 underwent robotic thoracic surgery. The tissue oxygen saturation value decreased gradually toward the tip of the conduit, as did congestion, and was significantly decreased at the tip compared with the value at the demarcation line (P = .001). Mean tissue oxygen saturation differed significantly between the leakage and no-leakage groups at the anastomosis site (P = .04). We found a negative correlation between tissue oxygen saturation and indocyanine green values at the end of the right gastroepiploic artery (r = -0.361; P = .03).

CONCLUSION

Tissue oxygen saturation imaging was useful in determining the anastomotic site and addressed the disadvantages associated with indocyanine green.

A novel device to assess the oxygen saturation and congestion status of the gastric conduit in thoracic esophagectomy

BACKGROUND

In thoracic esophagectomy, anastomotic leakage is one of the most important surgical complications. Indocyanine green (ICG) is the most widely used method to assess tissue blood flow; however, this technique has been pointed out to have disadvantages such as difficulty in evaluating the degree of congestion, lack of objectivity in evaluating the degree of staining, and bias easily caused by ICG injection, camera distance, and other factors. Evaluating tissue oxygen saturation (StO2) overcomes these disadvantages and can be performed easily and repeatedly. It is also possible to measure objective values including the degree of congestion. We evaluate novel imaging technology to assess tissue oxygen saturation (StO2) in the gastric conduit during thoracic esophagectomy.

METHODS

Fifty patients were enrolled, with seven excluded due to intraoperative findings, leaving 43 for analysis. These patients underwent thoracic esophagectomy for esophageal cancer. The device was used intraoperatively to evaluate tissue oxygen saturation (StO2) and total hemoglobin index (T-HbI), which guided the optimal site for gastric tube anastomosis. The efficacies of StO2 and T-HbI in relation to short-term outcomes were analyzed.

RESULTS

StO2, indicating blood supply to the gastric tube, remained stable beyond the right gastroepiploic artery (RGEA) end but significantly decreased distally to the demarcation line (p <  0.05). T-HbI, indicative of congestion, significantly decreased past the RGEA (p <  0.05). Three patients experienced anastomotic leakage. These patients exhibited significantly lower StO2 (p <  0.01) and higher T-HbI (p <  0.01) at both the RGEA end and the demarcation line. Furthermore, the anastomotic site, usually within 3 cm of the RGEA's anorectal side, also showed significantly lower StO2 (p <  0.01) and higher T-HbI (p <  0.01) in patients with anastomotic leakage.

CONCLUSIONS

The novel device provides real-time, objective evaluations of blood flow and congestion in the gastric tube. It proves useful for safer reconstruction during thoracic esophagectomy, particularly by identifying optimal anastomosis sites and predicting potential anastomotic leakage.

Anaphylactic Shock to Intravenous Indocyanine Green During a Robotic Right Colectomy

Intravenous indocyanine green (IV ICG) is regarded as a safe immunofluorescence agent used to assess bowel perfusion prior to creating bowel anastomoses and aids in ureter identification during intra-abdominal surgery. We report the first instance of anaphylactic shock to IV ICG after prior toleration of ICG via an intra-ureteral route. Shortly after administering IV ICG, our patient became hypotensive and hypoxic requiring chest compressions, vasoactive medications, and thoracostomy tubes prior to identifying the symptoms as an allergic reaction. Anaphylaxis is not a recognized side effect of ICG and was not immediately considered. As ICG becomes increasingly utilized as an immunofluorescence agent among surgical specialties, increased awareness and recognition of anaphylactic shock as a potential side effect of ICG may lead to expedited diagnoses, treatment, and more critical evaluation of indications for future use. Additionally, our patient first tolerated intra-ureteral administration without a systemic reaction, suggesting a possible sensitization mechanism.

Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report

BACKGROUND

Laparoscopic choledocholithotomy for a large impacted common bile duct (CBD) stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications, even in this era of minimally invasive surgery. Herein, we present a case of large impacted CBD stones.

CASE SUMMARY

A 71-year-old man showed a distal CBD stone (45 mm × 20 mm) and a middle CBD stone (20 mm × 15 mm) on computed tomography. Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum. Laparoscopic choledocholithotomy was decided, and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately. Then, the location, size, and shape of the stones were detected using a laparoscopic intraoperative ultrasound. The CBD was opened with a 2-cm-sized vertical incision. After irrigating several times, two CBD stones were removed with the Endo BabcockTM. T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge. The patient had no postoperative complications.

CONCLUSION

Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Flap Viability Evaluation Using a Tissue Oximetry Camera as an Alternative to Indocyanine Green Fluorescence Imaging

Indocyanine green (ICG) fluorescence imaging is useful for assessing flap viability; however, it is associated with a risk of anaphylactic shock, even in patients with no history of drug allergies. SnapshotNIR is a noncontact, camera-type handheld tissue oximeter that can measure the tissue oxygen saturation of the body surface. The device emits red and near infrared light wavelengths and then optimizes the measurement of the differential reflectance from oxygenated and deoxygenated hemoglobin, and StO2 is calculated. A 20 × 15 cm surgical field can be evaluated in less than 3 seconds by holding the camera at a distance of 30 cm. We applied this device at zone II in a deep inferior epigastric perforator (DIEP) flap, and compared the findings with the border of flap perfusion detected by ICG imaging. Left breast reconstruction using a free DIEP flap was performed for a 60-year-old woman. The DIEP flap was vascularized by a perforator vessel coursing to the right abdominis muscle. First, Diagnogreen (5 mg; Daiichi Sankyo Co., Tokyo, Japan) was intravenously injected, and the ICG fluorescence perfusion border detected by PDE-neo (Hamamatsu Photonics, Hamamatsu City, Shizuoka, Japan) was determined. The ICG border was defined by two reconstructive surgeons after fluorescence had spread out for 2 minutes. Next, zones Ⅱ and Ⅳ of the DIEP flap, contralateral to the perforator, were evaluated using photographs obtained by SnapshotNIR. There were significant StO2 value differences between the ICG-negative area and ICG-positive area. This device can be widely applied in the noninvasive evaluation of flap viability.

Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases

Choosing reliable recipient vessels is crucial for successful free flap reconstruction of lower extremity defects, especially in patients with ischemic vasculopathy. This report describes our experience with the intraoperative use of indocyanine green angiography (ICGA) for selecting recipient vessels in lower extremity free flap reconstruction cases. Three patients with lower extremity defects and ischemic vasculopathy underwent free flap reconstruction. Intraoperatively, the candidate vessels were evaluated using ICGA. In the first case, a 10 × 6 cm defect on the anterior side of the lower third of the leg caused by minor trauma and associated with peripheral arterial occlusive disease was reconstructed using a super-thin anterolateral thigh flap based on one perforator. In the second case, a 12 × 8 cm defect on the posterior side of the right lower leg caused by a dog bite and associated with severe atherosclerosis throughout all three major vessels in the lower leg was reconstructed using a muscle-sparing latissimus dorsi myocutaneous flap. In the third case, a 13.5 × 5.5 cm defect on the right lateral malleolar region, where the peroneus longus tendon was exposed due to Buerger's disease, was reconstructed using a one perforator-based super-thin anterolateral thigh flap. In all cases, ICGA was used to evaluate the functionality of the candidate recipient vessels. In two cases, the candidate vessels showed acceptable blood flow, and the operations proceeded as planned. In the third case, the planned vessels of posterior tibial vessels were not identified to have sufficient blood flow, and one of their branches showing enhancement in ICGA was selected and used as a recipient vessel. All flaps survived completely. No adverse events occurred during the follow-up period of postoperative 3 months. Our results suggest that ICGA may be a valuable diagnostic tool for evaluating the quality of candidate recipient vessels in cases where their functionality cannot be guaranteed with conventional imaging modalities.

Pudexacianinium (ASP5354) chloride for ureter visualization in participants undergoing laparoscopic, minimally invasive colorectal surgery

BACKGROUND

Intraoperative ureteral injury, a serious complication of abdominopelvic surgeries, can be avoided through ureter visualization. Near-infrared fluorescence imaging offers real-time anatomical visualization of ureters during surgery. Pudexacianinium (ASP5354) chloride is an indocyanine green derivative under investigation for intraoperative ureter visualization during colorectal or gynecologic surgery in adult and pediatric patients.

METHODS

In this phase 2 study (NCT04238481), adults undergoing laparoscopic colorectal surgery were randomized to receive one intravenous dose of pudexacianinium 0.3 mg, 1.0 mg, or 3.0 mg. The primary endpoint was successful intraoperative ureter visualization, defined as observation of ureter fluorescence 30 min after pudexacianinium administration and at end of surgery. Safety and pharmacokinetics were also assessed.

RESULTS

Participants received pudexacianinium 0.3 mg (n = 3), 1.0 mg (n = 6), or 3.0 mg (n = 3). Most participants were female (n = 10; 83.3%); median age was 54 years (range 24-69) and median BMI was 29.3 kg/m2 (range 18.7-38.1). Successful intraoperative ureter visualization occurred in 2/3, 5/6, and 3/3 participants who received pudexacianinium 0.3 mg, 1.0 mg, or 3.0 mg, respectively. Median intensity values per surgeon assessment were 1 (mild) with the 0.3-mg dose, 2 (moderate) with the 1.0-mg dose, and 3 (strong) with the 3.0-mg dose. A correlation was observed between qualitative (surgeon's recognition/identification of the ureter during surgery) and quantitative (video recordings of the surgeries after study completion) assessment of fluorescence intensity. Two participants experienced serious adverse events, none of which were drug-related toxicities. One adverse event (grade 1 proteinuria) was related to pudexacianinium. Plasma pudexacianinium concentrations were dose-dependent and the mean (± SD) percent excreted into urine during surgery was 22.3% ± 8.0% (0.3-mg dose), 15.6% ± 10.0% (1.0-mg dose), and 39.5% ± 12.4% (3.0-mg dose).

CONCLUSIONS

In this study, 1.0 and 3.0 mg pudexacianinium provided ureteral visualization for the duration of minimally invasive, laparoscopic colorectal procedures and was safe and well tolerated.

Role of Indocyanine Green Angiography in Free Flap Surgery: A Comparative Outcome Analysis of a Single-Center Large Series of 877 Consecutive Free Flaps

Purpose  This study aims to assess and validate the role and cost-effectiveness of indocyanine green angiography (ICGA) in free flap surgery outcomes. A new intraoperative protocol of whole-body surface warming (WBSW) for all free flap surgeries during the strategic "microbreaks" is also described. Methods  A retrospective analysis of 877 consecutive free flaps, performed over 12 years, is presented. The results of the ICGA group ( n  = 438) were compared with the historical No-ICGA group ( n  = 439), and statistical significance was calculated for three crucial flap-related adverse outcomes and cost-effectiveness. ICGA was also used as a tool to show the effect of WBSW on free flaps. Results  ICGA showed a notably strong statistical significance in decreasing two outcome parameters, namely, partial flap loss and re-exploration rate. It was also cost-effective. ICGA also demonstrated the positive role of WBSW in increasing flap perfusion. Conclusions  Our study shows that the usage of ICGA for intraoperative assessment of flap perfusion can significantly reduce the partial flap loss and re-exploration rate in free flap surgeries in a cost-effective manner. A new protocol of WBSW is also described and recommended to increase flap perfusion in all free flap surgeries.

Applications of Indocyanine Green-Guided Near-Infrared Fluorescence Imaging in Pediatric Minimally Invasive Surgery Urology: A Narrative Review

Background: Indocyanine green (ICG) is a fluorescent dye used for several indications in adult surgery, and, more recently, adopted also in the pediatric patients. This study aimed to review the literature published on the use of ICG near-infrared fluorescence (NIRF) in pediatric urology, to address its shortcomings and disadvantages and to detect the future perspectives. Materials and Methods: An electronic literature search of PubMed on all studies reporting use of ICG-NIRF in pediatrics was performed. We included only studies reporting ICG-NIRF application in minimally invasive surgery (MIS) for pediatric urology indications. Results: Forty-two articles reporting MIS procedures performed using ICG-NIRF in children were obtained, but only 15 studies that focused on urological applications of ICG-NIRF in children were included in this review. The included studies described use of ICG-NIRF for kidney malformations such as duplex system, kidney tumors, renal cysts, ureteral pathology, bladder malformations, varicocele, and lymph node sampling in tumors. The pediatric urological applications in which ICG-NIRF provided significant advantages included partial nephrectomy, lymphatics sparing varicocele repair, and oncological procedures. The ICG-NIRF use was clinically safe, without reported adverse systemic reactions in all pediatric series. The main drawback of this technology is the need of specific laparoscopic equipment such as camera system, light sources, and telescopes or the da Vinci Xi Robot, with the software for ICG-NIRF, Firefly^®, already integrated within. Conclusions: ICG-enhanced fluorescence-guided surgery is gaining growing popularity among pediatric surgeons due to the excellent results that have been published until now. ICG-NIRF technology has proven to be safe, easy to use, not time-consuming, cheap, and very effective to improve intraoperative view and surgical ability. Nonetheless, further evidence, including larger series, longer follow-up, and more specific assessments, is necessary to confirm the preliminary results and enlarge the applications.

A novel imaging technology to assess oxygen saturation of the gastric conduit in thoracic esophagectomy

BACKGROUND

Real-time evaluation of blood perfusion is important when selecting the site of anastomosis during thoracic esophagectomy. This study investigated a novel imaging technology that assesses tissue oxygen saturation (StO2) in the gastric conduit and examined its efficacy.

METHODS

Fifty-one patients undergoing thoracic esophagectomy for esophageal cancer who underwent intraoperative StO2 endoscopic imaging to assess the gastric conduit for the optimal site of anastomosis were examined. Efficacy of oxygen saturation imaging and patient outcomes were analyzed.

RESULTS

All 51 patients underwent esophagectomy without intraoperative problems. Mean StO2 in the gastric tube was highest at the pre-pylorus area and then gradually decreased proceeding toward the tip. StO2 was well preserved in areas supplied by the right gastroepiploic artery but low in other areas. Anastomotic sites were selected based on StO2 imaging and tension considerations; most were located within 3 cm of the end of the right gastroepiploic artery. Three patients developed postoperative anastomotic leakage (5.8%). Mean StO2 at the point of anastomosis was significantly lower in the patients who experienced leakage than in those who did not (P = 0.04).

CONCLUSION

Intraoperative endoscopic StO2 imaging is useful in esophageal cancer patients undergoing thoracic esophagectomy to determine the optimal site for anastomosis to minimize the risk of anastomotic leakage.

Utility of X-ray and indocyanine green fluorescence imaging in detecting hepatocellular carcinoma dissemination on laparoscopic surgery: A case report

Indocyanine green (ICG) fluorescence imaging is useful for the intraoperative detection of the peritoneal dissemination of hepatocellular carcinoma (HCC). However, in laparoscopic surgery, disseminations cannot be accurately identified unless the camera lens is positioned close to the lesion. The present study describes a case of HCC dissemination in which the lesions were accurately identified by combining intraoperative fluoroscopy with ICG fluorescence imaging. A 76-year-old male was diagnosed with HCC dissemination. Computed tomography revealed a 9-mm disseminated nodule near the gallbladder. Although transarterial chemoembolization had also been used to treat this lesion, chemoembolization was technically difficult to perform. Therefore, a coil was placed around the lesion to serve as an intraoperative landmark for later laparoscopic resection. Given the potential difficulty of detecting the lesion during laparoscopic surgery, ICG fluorescence imaging was used to determine the approximate location of the dissemination. The lesion exhibited strong fluorescence, which facilitated its complete resection.

Clinical effect and standardization of indocyanine green angiography in the laparoscopic colorectal surgery

Anastomotic complications occur after 5% to 20% of operations for rectosigmoid colon cancer. The intestinal perfusion status at the anastomotic site is an important modifiable risk factor, and surgeons should carefully evaluate and optimize the perfusion at the intended site of anastomosis. Indocyanine green (ICG) angiography is a simple noninvasive perfusion assessment modality. The use of ICG angiography is rapidly spreading in the field of colorectal surgery. However, there is debate on its contribution to reducing anastomotic complications. In this review, we discuss the clinical utility and the standardization of ICG angiography. ICG angiography can unequivocally reveal unfavorable perfusion zones and provide quantitative parameters to predict the risk of hypoperfusion-related anastomotic complications. Many studies have demonstrated the clinical utility of ICG angiography for reducing anastomotic complications. Recently, two multicenter randomized clinical trials reported that ICG angiography did not significantly reduce the incidence of anastomotic leakage. Most previous studies have been small-scale single-center studies, and there is no standardized ICG angiography protocol to date. Additionally, ICG angiography evaluations have mostly relied on surgeons’ subjective judgment. For these reasons, it is necessary to establish a standardized ICG angiography protocol and develop a quantitative analysis protocol for the objective assessment. In conclusion, ICG angiography could be useful for detecting poorly perfused colorectal segments to prevent anastomotic leakage after colorectal surgery. An optimized and standardized ICG angiography protocol should be established to improve the reliability of perfusion assessments. In the future, artificial intelligence-based quantitative analyses could be used to easily assess colonic perfusion status.

Fluorescence angiography-assisted debridement of critically perfused glabrous skin in degloving foot injuries: Two case reports

RATIONALE

Degloving foot injuries are challenging to treat and associated with life-long sequelae for patients. An appropriate debridement of ischemic soft tissues with maximal preservation of glabrous skin is key during the reconstruction of these injuries. Indocyanine green (ICG) fluorescence angiography is an established technique for the intraoperative evaluation of tissue perfusion.

PATIENT CONCERNS

Two patients sustained complex foot injuries in traffic accidents, including multiple fracture dislocations and extensive degloving of the plantar skin.

DIAGNOSIS

Clinical inspection revealed significant degloving of the glabrous skin in both patients.

INTERVENTIONS

After fracture fixation, ICG fluorescence angiography-assisted debridement with immediate latissimus dorsi free flap reconstruction was performed.

OUTCOMES

In both cases, this technique allowed a precise debridement with maximal preservation of the glabrous skin. The healing of the remaining glabrous skin was uneventful and the 6-month follow-up was characterized by stable soft tissues and satisfying ambulation.

LESSONS

ICG fluorescence angiography is a safe, user-friendly, and quick procedure with minimal risks, expanding the armamentarium of the reconstructive surgeon. It is highly useful for the debridement of extensive plantar degloving injuries and may also help to minimize the number of procedures and the risk of infection.

Sentinel lymph node biopsy in patients with endometrial cancer and an indocyanine green or iodinated contrast reaction - A proposed management algorithm

OBJECTIVE

To describe the incidence of adverse reactions to indocyanine green (ICG) administered during sentinel lymph node (SLN) biopsy for endometrial cancer, and to propose an ICG management algorithm for these patients.

METHODS

All patients who underwent surgery for endometrial cancer with SLN biopsy using ICG from 1/2017 to 8/2020 were identified using a single-institution prospective database. Surgical adverse events (SAEs) related to the procedure were identified. A review of the literature was performed.

RESULTS

In all, 1414 patients met inclusion criteria and were evaluated. Sixty-seven (4.7%) patients had a history of either an iodine or contrast allergy. No patients had a history of documented ICG allergy. Among patients with an iodine or contrast allergy, 65 (97%) received a corticosteroid with or without diphenhydramine prior to ICG administration. One hundred five patients (7.4%) experienced 116 SAEs. Among these patients, 3 experienced potentially allergic SAEs possibly related to ICG administration. After thorough chart review, however, the likelihood these SAEs were due to ICG appeared low. No patients experienced an anaphylactic response after ICG admission.

CONCLUSION

There were no anaphylactic reactions to ICG intracervical administration during 1414 consecutive SLN biopsies, including in patients with a documented iodine or contrast allergy. Intracervical injection of ICG is safe, and premedication using corticosteroids with or without diphenhydramine prior to SLN biopsy is a reasonable strategy in patients with iodinated contrast allergy.

Effectiveness of Intraoperative Indocyanine Green Fluorescence-Navigated Surgery for Superior Mesenteric Vein Thrombosis that Developed During Treatment for Intravascular Lymphoma: A Case Report

BACKGROUND Superior mesenteric vein thrombosis (SMVT) is a relatively rare form of acute abdominal disease; less than 0.1% of laparotomy surgeries are performed for SMVT. In the presence of severe intestinal ischemia or necrosis caused by SMVT, immediate surgical intervention is required. Macroscopic diagnosis of intestinal viability is sometimes difficult; its over-resection may carry the risk of short bowel syndrome. A near-infrared fluorescence imaging system with indocyanine green (ICG) has recently been developed for intraoperative, real-time evaluation of intestinal perfusion. This is the first report on the use of ICG fluorescence imaging during surgery for intestinal ischemia caused by venous thrombosis. CASE REPORT A 70-year-old man presented with a general feeling of weariness. On examination, he was diagnosed with intravascular large B cell lymphoma. R-CHOP therapy was initiated. On day 3 of initial R-CHOP therapy, the patient experienced sudden severe abdominal pain while in the hospital. Contrast-enhanced computed tomography revealed SMVT and loss of contrast effect in the small intestine. We diagnosed small bowel necrosis caused by SMVT, and exploratory laparotomy was performed, which revealed a continuous ischemia of 150 cm. Intraoperative ICG fluorescence imaging was utilized, and the color boundary was consistent with the ischemic area detected by visualization. The necrotic small intestine was excised and anastomosed. The patient was transferred to the hematology department on postoperative day 10 with no severe complications such as anastomotic leakage or re-thrombosis, and re-embolization was not observed 6 months later. CONCLUSIONS Venous thrombosis should be listed as a differential diagnosis when acute abdominal disease presents during chemotherapy for malignant lymphoma. ICG fluorescence imaging may be useful in the evaluation of intestinal blood flow for venous thrombosis.