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Faber RA, Tange FP, Galema HA, Zwaan TC, Holman FA, Peeters KCMJ, Tanis PJ, Verhoef C, Burggraaf J, Mieog JSD, Hutteman M, Keereweer S, Vahrmeijer AL, van der Vorst JR, Hilling DE. Quantification of indocyanine green near-infrared fluorescence bowel perfusion assessment in colorectal surgery. Surg Endosc 2023; 37:6824-6833. [PMID: 37286750 PMCID: PMC10462565 DOI: 10.1007/s00464-023-10140-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Indocyanine green near-infrared fluorescence bowel perfusion assessment has shown its potential benefit in preventing anastomotic leakage. However, the surgeon's subjective visual interpretation of the fluorescence signal limits the validity and reproducibility of the technique. Therefore, this study aimed to identify objective quantified bowel perfusion patterns in patients undergoing colorectal surgery using a standardized imaging protocol. METHOD A standardized fluorescence video was recorded. Postoperatively, the fluorescence videos were quantified by drawing contiguous region of interests (ROIs) on the bowel. For each ROI, a time-intensity curve was plotted from which perfusion parameters (n = 10) were derived and analyzed. Furthermore, the inter-observer agreement of the surgeon's subjective interpretation of the fluorescence signal was assessed. RESULTS Twenty patients who underwent colorectal surgery were included in the study. Based on the quantified time-intensity curves, three different perfusion patterns were identified. Similar for both the ileum and colon, perfusion pattern 1 had a steep inflow that reached its peak fluorescence intensity rapidly, followed by a steep outflow. Perfusion pattern 2 had a relatively flat outflow slope immediately followed by its plateau phase. Perfusion pattern 3 only reached its peak fluorescence intensity after 3 min with a slow inflow gradient preceding it. The inter-observer agreement was poor-moderate (Intraclass Correlation Coefficient (ICC): 0.378, 95% CI 0.210-0.579). CONCLUSION This study showed that quantification of bowel perfusion is a feasible method to differentiate between different perfusion patterns. In addition, the poor-moderate inter-observer agreement of the subjective interpretation of the fluorescence signal between surgeons emphasizes the need for objective quantification.
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Affiliation(s)
- Robin A Faber
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Floris P Tange
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Thomas C Zwaan
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Fabian A Holman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieter J Tanis
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Centre of Human Drug Research, Zernikedreef 8, 2333 CL, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Merlijn Hutteman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Joost R van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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Tange FP, van den Hoven P, van Schaik J, Schepers A, van der Bogt KEA, van Rijswijk CSP, Putter H, Vahrmeijer AL, Hamming JF, van der Vorst JR. Near-Infrared Fluorescence Imaging With Indocyanine Green to Predict Clinical Outcome After Revascularization in Lower Extremity Arterial Disease. Angiology 2023:33197231186096. [PMID: 37358400 DOI: 10.1177/00033197231186096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
Contemporary quality control methods are often insufficient in predicting clinical outcomes after revascularization in lower extremity arterial disease (LEAD) patients. This study evaluates the potential of near-infrared fluorescence imaging with indocyanine green to predict the clinical outcome following revascularization. Near-infrared fluorescence imaging was performed before and within 5 days following the revascularization procedure. Clinical improvement was defined as substantial improvement of pain free walking distance, reduction of rest- and/or nocturnal pain, or tendency toward wound healing. Time-intensity curves and 8 perfusion parameters were extracted from the dorsum of the treated foot. The quantified postinterventional perfusion improvement was compared within the clinical outcome groups. Successful near-infrared fluorescence imaging was performed in 72 patients (76 limbs, 52.6% claudication, 47.4% chronic limb-threatening ischemia) including 40 endovascular- and 36 surgical/hybrid revascularizations. Clinical improvement was observed in 61 patients. All perfusion parameters showed a significant postinterventional difference in the clinical improvement group (P-values <.001), while no significant differences were seen in the group without clinical improvement (P-values .168-.929). Four parameters demonstrated significant differences in percentage improvement comparing the outcome groups (P-values within .002-.006). Near-infrared fluorescence imaging has promising additional value besides clinical parameters for predicting the clinical outcome of revascularized LEAD patients.
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Affiliation(s)
- Floris P Tange
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Pim van den Hoven
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | | | | | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, The Netherlands
| | | | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, The Netherlands
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Galema HA, Faber RA, Tange FP, Hilling DE, van der Vorst JR, Hartgrink HH, Vahrmeijer AL, Hutteman M, Mieog JSD, Lagarde SM, van der Sluis PC, Wijnhoven BP, Verhoef C, Burggraaf J, Keereweer S. A quantitative assessment of perfusion of the gastric conduit after oesophagectomy using near-infrared fluorescence with indocyanine green. Eur J Surg Oncol 2023; 49:990-995. [PMID: 36914531 DOI: 10.1016/j.ejso.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/20/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Anastomotic leakage is a severe complication after oesophageal resection with gastric conduit reconstruction. Poor perfusion of the gastric conduit plays an important role in the development of anastomotic leakage. Quantitative near-infrared (NIR) fluorescence angiography with indocyanine green (ICG-FA) is an objective technique that can be used for perfusion assessment. This study aims to assess perfusion patterns of the gastric conduit with quantitative ICG-FA. METHODS In this exploratory study, 20 patients undergoing oesophagectomy with gastric conduit reconstruction were included. A standardized NIR ICG-FA video of the gastric conduit was recorded. Postoperatively, the videos were quantified. Primary outcomes were the time-intensity curves and nine perfusion parameters from contiguous regions of interest on the gastric conduit. A secondary outcome was the inter-observer agreement of subjective interpretation of the ICG-FA videos between six surgeons. The inter-observer agreement was tested with an intraclass correlation coefficient (ICC). RESULTS In a total of 427 curves, three distinct perfusion patterns were recognized: pattern 1 (steep inflow, steep outflow); pattern 2 (steep inflow, minor outflow); and pattern 3 (slow inflow, no outflow). All perfusion parameters were significantly different between the perfusion patterns. The inter-observer agreement was poor - moderate (ICC:0.345,95%CI:0.164-0.584). DISCUSSION This was the first study to describe perfusion patterns of the complete gastric conduit after oesophagectomy. Three distinct perfusion patterns were observed. The poor inter-observer agreement of the subjective assessment underlines the need for quantification of ICG-FA of the gastric conduit. Further studies should evaluate the predictive value of perfusion patterns and parameters on anastomotic leakage.
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Affiliation(s)
- Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands; Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Robin A Faber
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Floris P Tange
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Denise E Hilling
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands; Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Joost R van der Vorst
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
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Tange FP, Ferrari BR, van den Hoven P, van Schaik J, Schepers A, van Rijswijk CSP, van der Meer RW, Putter H, Vahrmeijer AL, Hamming JF, van der Vorst JR. Evaluation of the Angiosome Concept Using Near-Infrared Fluorescence Imaging with Indocyanine Green. Ann Vasc Surg 2023:S0890-5096(23)00018-3. [PMID: 36642169 DOI: 10.1016/j.avsg.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/29/2022] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND The angiosome concept is defined as the anatomical territory of a source artery within all tissue layers. When applying this theory in vascular surgery, direct revascularization (DR) is preferred to achieve increased blood flow toward the targeted angiosome of the foot in patients with lower extremity arterial disease (LEAD). This study evaluates the applicability of the angiosome concept using quantified near-infrared (NIR) fluorescence imaging with indocyanine green (ICG). METHODS This study included patients undergoing an endovascular- or surgical revascularization of the leg between January 2019 and December 2021. Preinterventional and postinterventional ICG NIR fluorescence imaging was performed. Three angiosomes on the dorsum of the foot were determined: the posterior tibial artery (hallux), the anterior tibial artery (dorsum of the foot) and the combined angiosome (second to fifth digit). The angiosomes were classified from the electronic patient records and the degree of collateralization was classified based on preprocedural computed tomography angiography and/or X-ray angiography. Fluorescence intensity was quantified in all angiosomes. A subgroup analysis based on endovascular or surgical revascularized angiosomes, and within critical limb threatening ischemia (CLTI) patients was performed. RESULTS ICG NIR fluorescence measurements were obtained in 52 patients (54 limbs) including a total of 157 angiosomes (121 DR and 36 indirect revascularizations [IR]). A significant improvement of all perfusion parameters in both the directly and indirectly revascularized angiosomes was found (P-values between <0.001-0.007). Within the indirectly revascularized angiosomes, 90.6% of the scored collaterals were classified as significant. When comparing the percentual change in perfusion parameters between the directly and indirectly revascularized angiosomes, no significant difference was seen in all perfusion parameters (P-values between 0.253 and 0.881). Similar results were shown in the CLTI patients subgroup analysis, displaying a significant improvement of perfusion parameters in both the direct and indirect angiosome groups (P-values between <0.001 and 0.007), and no significant difference when comparing the percentual parameter improvement between both angiosome groups (P-values between 0.134 and 0.359). Furthermore, no significant differences were observed when comparing percentual changes of perfusion parameters in directly and indirectly revascularized angiosomes for both endovascular and surgical interventions (P-values between 0.053 and 0.899). CONCLUSIONS This study proves that both DR and IR of an angiosome leads to an improvement of perfusion. This suggests that interventional strategies should not only focus on creating in-line flow to the supplying angiosome. One can argue that the angiosome concept is not applicable in patients with LEAD.
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Affiliation(s)
- Floris P Tange
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bien R Ferrari
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pim van den Hoven
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Rutger W van der Meer
- Department of Interventional Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Hoven PVD, Verduijn PS, Van Capelle L, Tange FP, Michi M, Corion LUM, Mulder BGS, Mureau MAM, Vahrmeijer AL, Van Der Vorst JR. Quantification of Near-Infrared Fluorescence Imaging with Indocyanine Green in Free Flap Breast Reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:1820-1825. [DOI: 10.1016/j.bjps.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/11/2021] [Accepted: 12/19/2021] [Indexed: 10/19/2022]
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