Intraoperative indocyanine green fluorescence angiography to prevent anastomotic leak after low anterior resection for rectal cancer: a meta‐analysis

Impact of indocyanine green angiography on anastomotic dehiscence rate in colorectal surgery: a systematic review and meta-analysis of randomized studies

Anastomotic dehiscence, a feared complication in colorectal surgery, motivates the search for effective strategies to mitigate its risk. This meta-analysis encompasses all published randomized trials investigating and comparing the impact of indocyanine green (ICG) angiography on this complication. With four studies and 1,109 patients, the intraoperative ICG angiography group demonstrated a significant reduction in the overall rate of anastomotic dehiscence compared to the non-angiography group (7.3% vs. 11.5%; OR: 0.6; 95% CI: 0.4-0.9; p = 0.03). These differences were maintained in rectal surgery subgroup, with no prolongation of surgical time or increase in morbidity and mortality. There were no differences in the left colon surgery group. The evidence provided by this meta-analysis would support the effectiveness of ICG angiography in reducing the incidence of anastomotic leakage in colorectal surgery, advocating for its integration into routine surgical practice.

Indocyanine green fluorescence-guided surgery in the emergency setting: the WSES international consensus position paper

BACKGROUND

Decision-making in emergency settings is inherently complex, requiring surgeons to rapidly evaluate various clinical, diagnostic, and environmental factors. The primary objective is to assess a patient's risk for adverse outcomes while balancing diagnoses, management strategies, and available resources. Recently, indocyanine green (ICG) fluorescence imaging has emerged as a valuable tool to enhance surgical vision, demonstrating proven benefits in elective surgeries.

AIM

This consensus paper provides evidence-based and expert opinion-based recommendations for the standardized use of ICG fluorescence imaging in emergency settings.

METHODS

Using the PICO framework, the consensus coordinator identified key research areas, topics, and questions regarding the implementation of ICG fluorescence-guided surgery in emergencies. A systematic literature review was conducted, and evidence was evaluated using the GRADE criteria. A panel of expert surgeons reviewed and refined statements and recommendations through a Delphi consensus process, culminating in final approval.

RESULTS

ICG fluorescence imaging, including angiography and cholangiography, improves intraoperative decision-making in emergency surgeries, potentially reducing procedure duration, complications, and hospital stays. Optimal use requires careful consideration of dosage and timing due to limited tissue penetration (5-10 mm) and variable performance in patients with significant inflammation, scarring, or obesity. ICG is contraindicated in patients with known allergies to iodine or iodine-based contrast agents. Successful implementation depends on appropriate training, availability of equipment, and careful patient selection.

CONCLUSIONS

Advanced technologies and intraoperative navigation techniques, such as ICG fluorescence-guided surgery, should be prioritized in emergency surgery to improve outcomes. This technology exemplifies precision surgery by enhancing minimally invasive approaches and providing superior real-time evaluation of bowel viability and biliary structures-areas traditionally reliant on the surgeon's visual assessment. Its adoption in emergency settings requires proper training, equipment availability, and standardized protocols. Further research is needed to evaluate cost-effectiveness and expand its applications in urgent surgical procedures.

Does indocyanine green fluorescence angiography reduce the risk of anastomotic leaks in colorectal resections? A systematic review and meta-analysis of randomized controlled trials

Anastomotic leaks are a significant complication in colorectal surgery. Indocyanine green fluorescence angiography (ICG-FA) has been suggested as a method to reduce the risk. This meta-analysis aims to evaluate the effect of ICG-FA on reducing anastomotic leaks in colorectal surgery. This study follows PRISMA guidelines and is registered on PROSPERO (CRD42022370748). We conducted a comprehensive search of multiple databases and registers for randomized controlled trials (RCTs) comparing ICG-FA with standard methods in colorectal surgery. Data extraction and quality assessment were performed by two independent reviewers, with a third resolving disputes. Odds ratios (OR) and mean differences (MD) were calculated using comprehensive meta-analysis software, version 3. Heterogeneity and publication bias were assessed, and a sensitivity analysis was performed. The analysis included five RCTs with a total of 1369 patients from four countries. The ICG-FA was associated with a 45% reduction in the risk of overall anastomotic leaks (OR: 0.550, p = 0.012). Subgroup analysis showed a 47% reduction in leaks for low anastomoses (OR: 0.53, p = 0.143) and a 69% reduction in grade A leaks (OR: 0.31, p = 0.008). No significant effects were observed for grade B and C leaks, blood loss, surgery duration, hospital stay, mortality, postoperative ileus, reoperation, or surgical site infections. ICG-FA significantly reduces the overall risk of anastomotic leaks, especially grade A leaks, and shows a trend towards fewer leaks in low anastomosis. No significant impact was found on secondary outcomes. Further RCTs are needed to confirm these findings.

Current applications of indocyanine green (ICG) in abdominal, gynecologic and urologic surgery: a meta-review and quality analysis with use of the AMSTAR 2 instrument

BACKGROUND

Indocyanine green (ICG) is an injectable fluorochrome that has recently gained popularity as a means of assisting intraoperative visualization during laparoscopic and robotic surgery. Many systematic reviews and meta-analyses have been published. We conducted a meta-review to synthesize the findings of these studies.

METHODS

PubMed and Embase were searched to identify systematic reviews and meta-analyses coping with the uses of ICG in abdominal operations, including Metabolic Bariatric Surgery, Cholecystectomy, Colorectal, Esophageal, Gastric, Hepato-Pancreato-Biliary, Obstetrics and Gynecology (OG), Pediatric Surgery, Surgical Oncology, Urology, (abdominal) Vascular Surgery, Adrenal and Splenic Surgery, and Interdisciplinary tasks, until September 2023. We submitted the retrieved meta-analyses to qualitative analysis based on the AMSTAR 2 instrument.

RESULTS

We identified 116 studies, 41 systematic reviews (SRs) and 75 meta-analyses (MAs), spanning 2013-2023. The most thoroughly investigated (sub)specialties were Colorectal (6 SRs, 25 MAs), OG (9 SRs, 15 MAs), and HPB (4 SRs, 12 MAs). Interestingly, there was high heterogeneity regarding the administered ICG doses, routes, and timing. The use of ICG offered a clear benefit regarding anastomotic leak prevention, particularly after colorectal and esophageal surgery. There was no clear benefit regarding sentinel node detection after OG. According to the AMSTAR 2 tool, most meta-analyses ranked as "critically low" (34.7%) or "low" (58.7%) quality. There were only five meta-analyses (6.7%) that qualified as "moderate" quality, whereas there were no "high" quality reviews.

CONCLUSIONS

Regardless of the abundance of pertinent literature and reviews, surgeons should be cautious when interpreting their results on ICG use in abdominal surgery. Future reviews should focus on ensuring methodological vigor; establishing clear protocols of ICG dose, route of administration, and timing; and improving reporting quality. Other sources of data (e.g., registries) and novel methods of data analysis (e.g., machine learning) might also contribute to an enhanced role of ICG as a decision-making tool in surgery.

Time required for indocyanine green fluorescence emission for evaluating bowel perfusion in left-sided colon and rectal cancer surgery

BACKGROUND

Indocyanine green fluorescence imaging (ICG-FI) has been reported to be useful in reducing the incidence of anastomotic leakage (AL) in colectomy. This study aimed to investigate the correlation between the required time for ICG fluorescence emission and AL in left-sided colon and rectal cancer surgery using the double-stapling technique (DST) anastomosis.

METHODS

This retrospective study included 217 patients with colorectal cancer who underwent left-sided colon and rectal surgery using ICG-FI-based perfusion assessment at our department between November 2018 and July 2022. We recorded the time required to achieve maximum fluorescence emission after ICG systemic injection and assessed its correlation with the occurrence of AL.

RESULTS

Among 217 patients, AL occurred in 21 patients (9.7%). The median time from ICG administration to maximum fluorescence emission was 32 s (range 25-58 s) in the AL group and 28 s (range 10-45 s) in the non-AL group (p < 0.001). The cut-off value for the presence of AL obtained from the ROC curve was 31 s. In 58 patients with a required time for ICG fluorescence of 31 s or longer, the following risk factors for AL were identified: low preoperative albumin [3.4 mg/dl (range 2.6-4.4) vs. 3.9 mg/dl (range 2.6-4.9), p = 0.016], absence of preoperative mechanical bowel preparation (53.8% vs. 91.1%, p = 0.005), obstructive tumor (61.5% vs. 17.8%, p = 0.004), and larger tumor diameter [65 mm (range 40-90) vs. 35 mm (range 4.0-100), p < 0.001].

CONCLUSION

The time required for ICG fluorescence emission was associated with AL.

Anastomotic Leak: Toward an Understanding of Its Root Causes

BACKGROUND

When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative.

METHODS

The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity.

RESULTS

No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak.

CONCLUSIONS

At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

Indocyanine green (ICG) fluorescence imaging is widely used in abdominal surgery. The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems. In that setting, ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow. The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery. Each type of use has been separately addressed and the evidence was investigated. During rectal resection, ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks. In addition, ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury. This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed. This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature. Although further studies are need to investigate the real clinical benefits, these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Effect of indocyanine green fluorescence angiography on preventing anastomotic leakage after colorectal surgery: a meta-analysis

Anastomotic leakage (AL) is a serious but not uncommon complication after colorectal surgery. We conducted this study to evaluate the effect of routine indocyanine green fluorescence angiography (ICG-FA) on reducing the AL rate after colorectal surgery. We identified all research articles about colorectal surgery using ICG-FA, published in the PubMed, EMBASE, and Cochrane Library databases from the date of database establishment to May 2020. Revman 5.3 was used for statistical analysis. We analyzed 22 controlled studies and 7 non-controlled studies on ICG-FA, including 6312 patients. The controlled studies included 2354 patients in the ICG group and 3522 patients in the non-ICG group. Meta-analysis showed that ICG-FA reduced the AL rate after colorectal surgery significantly (RR = 0.39; 95% CI 0.30-0.50; P < 0.00001). However, patients whose resection line was changed based on the fluorescence angiography had a higher AL rate than those whose resection line was not changed (OR = 5.37; 95% CI 2.67-10.81; P < 0.00001). The overall complication rate, severe complication rate, and reoperation rate in the ICG group were significantly lower than those in the non-ICG group (RR = 0.79, 95% CI 0.67-0.92, P = 0.002; RR = 0.67, 95% CI 0.47-0.96, P = 0.03; RR = 0.53, 95% CI 0.29-0.96, P = 0.04, respectively), whereas the postoperative ileus rate was significantly higher in the ICG group than in the non-ICG group (RR = 1.65; 95% CI 1.09-2.50; P = 0.02), especially in Western countries (RR = 1.6; 95% CI 1.04-2.47; P = 0.03).ICG-FA may reduce the AL rate after colorectal surgery, but ICG-FA group patients with transection line change for insufficient blood perfusion to the anastomotic stoma after evaluation had a higher AL rate than those without transection line change. Therefore, ICG-FA can help to identify patients at high risk of AL and intercept its occurrence. Moreover, ICG-FA may reduce the overall complication rate, severe complication rate, and reoperation rate, but induce postoperative ileus. High-quality randomized-controlled trials with a placebo control are needed to further evaluate the effectiveness and safety of ICG-FA.

New Anastomosis Technique to Prevent Anastomotic Leakage in Laparoscopic Anterior Resection for Rectal Cancer, Especially Upper Rectal Cancer

BACKGROUND/AIM

Anastomotic leakage (AL) is a major problem in rectal cancer surgery. To prevent AL, we developed a side-to-side anastomosis technique using a circular stapler and termed it the circular side stapling technique (CST). We herein report the method and outcome of the CST.

PATIENTS AND METHODS

In this study, we analyzed 154 patients with stage 0 to III rectal cancer who underwent curative laparoscopic low anterior resection. Perioperative factors and complications were compared between the CST and usual double stapling technique (DST).

RESULTS

The CST was performed in 110 of the 154 patients. When comparing the outcomes of patients with upper rectal cancer. AL occurred in no patients in the CST group and in three patients in the DST group (p=0.011). The CST prevented AL in all patients with upper rectal cancer.

CONCLUSION

The CST is a safe and useful procedure in laparoscopic anterior resection. This technique can prevent AL, especially in patients with upper rectal cancer.

Successful treatment of superior mesenteric artery thrombosis via preoperative interventional radiology and surgery using indocyanine green fluorescence

We report a successful case that offered a symbolic therapeutic experience of interventional radiology and surgery collaboration for superior mesenteric artery thrombosis. A 70-year-old man presented with a chief complaint of sudden abdominal pain. Contrast-enhanced computed tomography revealed superior mesenteric artery thrombosis. Interventional radiology was performed, and thrombotic occlusion was observed in the superior mesenteric artery trunk. The abdominal pain disappeared; however, after a while, the thrombus re-formed and the abdominal pain reappeared. Thus, emergency surgery was performed. Before surgery, thrombus aspiration was performed via interventional radiology as much as possible. During surgery, when the blood flow was evaluated using fluorescence with indocyanine green, a region of markedly poor blood flow was detected in the ileum, and the area was excised. The postoperative course was favorable. In this patient, it is possible that preoperative removal of the thrombus via interventional radiology minimized the ischemic area of the intestinal tract, and blood flow evaluation using indocyanine green allowed reliable excision of only the ischemic area. We believe that our case involved a treatment that exploited the advantages of both interventional radiology and surgery using indocyanine green fluorescence.

Indocyanine green fluorescence angiography prevents anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis

BACKGROUND

The role of intraoperative use of indocyanine green (ICG) fluorescence angiography (ICGFA) to prevent anastomotic leakage (AL) in rectal cancer surgery remains controversial.

METHODS

The systematic review for studies evaluating ICGFA in patients undergoing rectal cancer surgery in PubMed, Embase, Web of Science, and the Cochrane Library was performed up to April 30, 2020. The primary outcome was the incidence of AL. The analysis was performed using RevMan v5.3 and Stata v12.0 software.

RESULTS

Eighteen studies comprising 4038 patients were included. In the present meta-analysis, intraoperative use of ICGFA markedly reduced AL rate (OR = 0.33; 95% CI: 0.24-0.45; P < 0.0001; I2 = 0%) in rectal cancer surgery, which was still significant in surgeries limited to symptomatic AL (OR = 0.44; 95% CI: 0.31-0.64; P < 0.0001; I2 = 22%). This intervention was also associated with shorter postoperative stays (MD = - 1.27; 95% CI: - 2.42 to - 0.13; P = 0.04; I2 = 60%). However, reoperation rate (OR = 0.61; 95% CI: 0.34-1.10; P = 0.10; I2 = 6%), ileus rate (OR = 1.30; 95% CI: 0.60-2.82; P = 0.51; I2 = 56%), and surgical site infection rate (OR = 1.40; 95% CI: 0.62-3.20; P = 0.42; I2 = 0%) were not significantly different between the two groups.

CONCLUSION

The use of ICGFA was associated with a lower AL rate after rectal cancer resection. However, more multi-center RCTs with large sample size are required to further verify the value of ICGFA in rectal cancer surgery.

The incidence, risk factors, and new prediction score for fluorescence abnormalities of near-infrared imaging using indocyanine green in laparoscopic low anterior resection for rectal cancer

PURPOSE

Several studies have reported the efficacy of near-infrared imaging using indocyanine green in laparoscopic low anterior resection (LAR), but a detailed examination of its fluorescence abnormalities is still insufficient. The purpose of this study was to clarify the incidence of fluorescence abnormalities and to create a new prediction score in laparoscopic LAR.

METHODS

This was a retrospective, multicenter study that included patients with rectal cancer who underwent laparoscopic LAR from September 2014 to November 2018.

RESULTS

A total of 336 patients were included. The transection line was changed due to fluorescence abnormalities in 5.4% (18/336) of cases, and the median length of additional resection was 70 mm. Anastomotic leakage of Clavien-Dindo grade ≥ II occurred in 6.0% (20/336). The gender and the intraoperative pre-planned proximal margin (IpPM) were significant factors for fluorescence abnormalities. We devised the fluorescence abnormality prediction score (FAPS) derived from the gender, IpPM, and tumor height from the anal verge (TumorAV). The area under the curve of the FAPS was 0.784 (95% CI: 0.677-0.891). When the cutoff was 4, the sensitivity was 0.833, and the specificity was 0.626. The preoperative pre-planned proximal margin (PpPM) was calculated as follows: PpPM (mm) = 189 (mm) - TumorAV (mm) + 61 × Male (1/0). The proximal margin should be set to be larger than the PpPM to avoid fluorescence abnormalities.

CONCLUSION

The incidence of fluorescence abnormalities in laparoscopic LAR was 5.4%. If the FAPS is used, the PpPM may be set from the viewpoint of the blood perfusion.

TRIAL REGISTRATION

Japanese Clinical Trials Registry: UMIN000032654 ( http://www.umin.ac.jp/ctr/index.htm ).

Does near-infrared fluorescent cholangiography with indocyanine green reduce bile duct injuries and conversions to open surgery during laparoscopic or robotic cholecystectomy? - A meta-analysis

BACKGROUND

Bile duct injury and conversion-to-open-surgery rates remain unacceptably high during laparoscopic and robotic cholecystectomy. In a recently published randomized clinical trial, using near-infrared fluorescent cholangiography with indocyanine green intraoperatively markedly enhanced biliary-structure visualization. Our systematic literature review compares bile duct injury and conversion-to-open-surgery rates in patients undergoing laparoscopic or robotic cholecystectomy with versus without near-infrared fluorescent cholangiography.

METHODS

A thorough PubMed search was conducted to identify randomized clinical trials and nonrandomized clinical trials with ≥100 patients. Because all near-infrared fluorescent cholangiography studies were published since 2013, only studies without near-infrared fluorescent cholangiography published since 2013 were included for comparison. Incidence estimates, weighted and unweighted for study size, were adjusted for acute versus chronic cholecystitis, and for robotic versus laparoscopic cholecystectomy and are reported as events/10,000 patients. All studies were assessed for bias risk and high-risk studies excluded.

RESULTS

In total, 4,990 abstracts were reviewed, identifying 5 near-infrared fluorescent cholangiography studies (3 laparoscopic cholecystectomy/2 robotic cholecystectomy; n = 1,603) and 11 not near-infrared fluorescent cholangiography studies (5 laparoscopic cholecystectomy/4 robotic cholecystectomy/2 both; n = 5,070) for analysis. Overall weighted rates for bile duct injury and conversion were 6 and 16/10,000 in near-infrared fluorescent cholangiography patients versus 25 and 271/10,000 in patients without near-infrared fluorescent cholangiography. Among patients undergoing laparoscopic cholecystectomy, bile duct injuries, and conversion rates among near-infrared fluorescent cholangiography versus patients without near-infrared fluorescent cholangiography were 0 and 23/10,000 versus 32 and 255/10,000, respectively. Bile duct injury rates were low with robotic cholecystectomy with and without near-infrared fluorescent cholangiography (12 and 8/10,000), but there was a marked reduction in conversions with near-infrared fluorescent cholangiography (12 vs 322/10,000).

CONCLUSION

Although large comparative trials remain necessary, preliminary analysis suggests that using near-infrared fluorescent cholangiography with indocyanine green intraoperatively sizably decreases bile duct injury and conversion-to-open-surgery rates relative to cholecystectomy under white light alone.

The efficacy of intraoperative ICG fluorescence angiography on anastomotic leak after resection for colorectal cancer: a meta-analysis

OBJECTIVE

The purpose of this study was to investigate whether intraoperative indocyanine green fluorescence angiography can reduce the incidence of anastomotic leak.

METHODS

Present authors conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective nonrandomized trials, and retrospective trials up to March 2020. Eleven papers fulfilling the screening criteria were included.

INTERVENTION

Indocyanine green was injected intravenously after the division of the mesentery and colon but before anastomosis. The primary outcome measure was AL rate with at least 3 months of follow-up. Secondary outcome measure was operation time, postoperative complications, surgical site infection, reoperation, and ileus rate. The results were analyzed using STATA 12.0 software (Stata Corp, College Station, TX, USA).

RESULT

A total of 3137 patients were collected in 11 studies. Meta-analysis showed that compared with conventional surgery, the ICG fluorescence angiography resulted in a fewer AL rate (OR = 0.31; 95% CI 0.21 to 0.44; P < 0.0001), postoperative complications (OR = 0.70; 95% CI 0.51 to 0.96; P < 0.025), and reoperation rate (OR = 0.334; 95% CI 0.16 to 0.68; P = 0.003). Operation time (weighted mean difference - 25.162 min; 95% CI - 58.7 to 8.375; P = 0.141), surgical site infection rate (OR = 1.11; 95% CI 0.59 to 2.09; P = 0.742) did not differ between the two groups.

CONCLUSION

The result revealed that indocyanine green was associated with a lower anastomotic leakage rate after colorectal cancer resection. However, larger, multicentered, high-quality randomized controlled trials are needed to confirm the benefit of indocyanine green fluorescence angiography.

Does intraoperative indocyanine green fluorescence angiography decrease the incidence of anastomotic leakage in colorectal surgery? A systematic review and meta-analysis

BACKGROUND

Colorectal anastomoses in patients with colorectal cancer carry a high risk of leakage. Indocyanine green fluorescence angiography (ICG-FA) is a new technique that allows surgeons to assess the blood perfusion of the anastomosis during operation. This meta-analysis aimed to evaluate whether ICG-FA could prevent anastomotic leakage (AL) in colorectal surgery.

METHODS

Four databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched to identify suitable literatures until March 2020 that compared AL rates between intraoperative use and non-use of ICG-FA in colorectal surgery for cancer. The Review Manager 5.3 software was used to perform the statistical analysis. Evaluation of articles quality and analysis for publication bias were also conducted.

RESULTS

Thirteen studies of 4037 patients were included in the meta-analysis. The study included 1806 patients in the ICG group and 2231 patients in the control group. The pooled incidence of AL in ICG group was 3.8% compared with 7.8% in control group. There was a significant difference in AL rate with or without use of ICG-FA (OR 0.44; 95% CI 0.33-0.59; P < 0.00001). Reoperation rates were 2.6% and 6.9% in ICG and control groups, respectively. Application of intraoperative ICG-FA was associated with a lower risk of reoperation (OR 0.39; 95% CI 0.16-0.94; P = 0.04). Overall complication rate was 15.6% in the ICG group compared with 21.2% in the control group. Overall complications were significantly reduced when using ICG-FA (OR 0.62; 95% CI 0.47-0.82; P = 0.0008). Mortality rate was not statistically different with or without the use of ICG-FA (OR 1.22; 95% CI 0.20-7.30; P = 0.83).

CONCLUSION

The results revealed that ICG-FA reduced risks of AL, reoperation, and overall complications for colorectal cancer patients undergoing colorectal surgery. Well-designed RCTs are needed to confirm the usefulness of intraoperative ICG-FA for preventing surgical complications like AL and reoperation.

Indocyanine green fluorescent imaging on anastomotic leakage in colectomies: a network meta-analysis and systematic review

PURPOSE

The usage of indocyanine green (ICG) dye is commonly associated with decreased anastomotic leakage rates in colectomies. This study aims to perform a network meta-analysis to assess the usage of ICG fluorescence imaging in right-sided colectomies.

METHODS

Medline, Embase, Cochrane Trials, CNKI, and WanFang electronic databases were reviewed, and meta-analysis of proportions, comparative meta-analysis, and network meta-analysis were conducted in this review. Studies comparing ICG usage with conventional approaches of anastomosis were selected, with postoperative anastomotic leak rate being the primary outcome.

RESULTS

Ten articles were included, with a total of 675 patients involved, of which 515 patients underwent colorectal surgery with ICG. Anastomotic leak rates with ICG were estimated to be 1% (CI 0.00-0.04) and 3% (CI 0.01-0.06) for right and left procedures, respectively. No significant difference was observed in left-sided colectomies (OR 0.587; 95% CI 0.218-1.582; p = 0.292). There were nearly half the odds of anastomotic leakage when ICG was used in right-sided colectomies (OR 0.524; 95% CI 0.128-2.137).

CONCLUSION

With the ability to potentially avert postoperative anastomotic leakage, coupled with its minimal costs and side effects, administration of ICG in colectomies in centers where equipment is available should be encouraged.

Assessment of intraoperative use of indocyanine green fluorescence imaging on the incidence of anastomotic leakage after rectal cancer surgery: a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

The current data on the intraoperative use of indocyanine green (ICG) fluorescence imaging to reduce the anastomotic leak (AL) rate in rectal cancer surgery remain controversial. The aim of this systematic review and meta-analysis was to evaluate the efficacy of ICG fluorescence imaging in decreasing the AL rate after rectal cancer surgery.

METHODS

Studies comparing ICG fluorescence imaging with standard care in patients with rectal cancer were systematically searched from PubMed, Embase, Web of Science and Cochrane Library through January 2020. The current meta-analysis was performed according to the preferred reporting items for systematic review and meta-analysis guidelines. A pooled analysis was performed for the available data regarding the baseline features, AL rate and other surgical outcomes. RevMan version 5.3 software was used for the present meta-analysis.

RESULTS

Nine studies with a total of 2088 patients with rectal cancer (926 in the ICG group and 1162 in the control group) were included in the present study. In the pooled analysis, the available patient and tumour-related baseline data were all comparable and without significant heterogeneity. In the present pooled analysis, the AL rate in the ICG group was significantly lower (OR 0.34; 95% CI 0.22-0.52; p < 0.0001) than that in the control group. Additionally, intraoperative use of ICG was associated with a decreased overall complication rate (OR 0.57; 95% CI 0.42-0.78; p = 0.0003) and reduced reoperation rate (OR 0.26; 95% CI 0.08-0.86; p = 0.03) in patients who had rectal cancer surgery.

CONCLUSIONS

The present study demonstrated the superiority of the intraoperative use of ICG in reducing the AL rate. However, considering the limitations of the included studies, more high-quality prospective studies and randomized controlled trials are needed.

Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects

PURPOSE

In most cases, traditional techniques to perform an anastomosis following gastrointestinal resections lead to successful healing. However, despite focused research in the field, in certain high-risk situations leakage rates remain almost unchanged. Here, additional techniques may help the surgeon to protect the anastomosis and prevent leakage. We give an overview of some of the latest developments on experimental and clinical techniques for induction of anastomotic healing.

METHODS

We performed a review of the current literature on approaches to improve anastomotic healing.

RESULTS

Many promising approaches with a high clinical potential are in the developmental pipeline. Highly experimental approaches like inhibition of matrix metalloproteinases, stem cell therapy, hyperbaric oxygen therapy, induction of the hypoxic adaptive response, and the administration of growth factors are still in the preclinical phase. Other more clinical developments aim to strengthen the anastomotic suture line mechanically while shielding it from the influence of the microbiome. Among them are gluing, seaming the staple line, attachment of laminar biomaterials, and temporary intraluminal tubes. In addition, individualized bowel preparation, selectively reducing certain detrimental microbial populations could become the next stage of bowel preparation. Compression anastomoses are evolving as an equivalent technique additional to established hand-sewn and stapled anastomoses. Fluorescence angiography and flexible endoscopy could complement intraoperative quality control additionally to the air leak tests. Virtual ileostomy is a concept to prepare the bowel for the easy formation of a stoma in case of leakage.

CONCLUSION

A variety of promising diagnostic and prophylactic measures that may support the surgeon in identifying high-risk anastomoses and support them according to their potential deficits is currently in development.