Indocyanine Green Fluorescence Angiography Versus Visual Assessment for Assessing Perfusion of Gastric Conduit and Esophageal Stump in Post Esophagectomy Patients: A Pilot Randomized Controlled Study
Subramanyeshwar Rao Thammineedi
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorSujit Chyau Patnaik
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorPratap Reddy
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorAjesh Raj Saksena
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorSrijan Shukla
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorMakayla E. Schissel
Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorLynette M. Smith
Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorChandrakanth Are
Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorCorresponding Author
Syed Nusrath
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Correspondence: Syed Nusrath ([email protected])
Search for more papers by this authorSubramanyeshwar Rao Thammineedi
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorSujit Chyau Patnaik
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorPratap Reddy
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorAjesh Raj Saksena
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorSrijan Shukla
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Search for more papers by this authorMakayla E. Schissel
Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorLynette M. Smith
Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorChandrakanth Are
Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, USA
Search for more papers by this authorCorresponding Author
Syed Nusrath
Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
Correspondence: Syed Nusrath ([email protected])
Search for more papers by this authorABSTRACT
Background and Objective
Anastomotic leak (AL) is a serious complication following esophagectomy and is often linked to poor perfusion of the gastric conduit (GC) and esophageal stump (EC). The aim of this study is to compare the efficacy of intraoperative Indocyanine green fluorescence angiography (ICG-FA) versus visual assessment VA) to assess perfusion status and its impact on the rate of AL.
Methods
Fifty-eight esophageal or gastroesophageal junction carcinoma patients were randomized to ICG-FA (28) and VA (30) groups. Perfusion status was assessed with VA alone in the VA group and with VA followed by ICG-FA in the ICG-FA group.
Results
The ICG-FA group had a lower leak rate of 4% when compared to 27% in the VA group (p = 0.03). ICG-FA identified nine cases where VA misjudged the GC tip vascularity, thereby avoiding unnecessary resections. ICG-FA necessitated revision of the GC tip in one case missed by VA and also identified poor perfusion of ES tip in three cases mandating revision which were deemed well-perfused by VA.
Conclusion
ICG-FA demonstrated superiority over VA in assessing perfusion adequacy of the GC and ES, which resulted in a statistically significant decrease in the rate of anastomotic leaks.
Open Research
Data Availability Statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
References
- 1J. Huang, A. Koulaouzidis, W. Marlicz, et al., “Global Burden, Risk Factors, and Trends of Esophageal Cancer: An Analysis of Cancer Registries From 48 Countries,” Cancers 13, no. 1 (2021 January 5): 141.
- 2M. Junemann-Ramirez, M. Awan, Z. Khan, and J. Rahamim, “Anastomotic Leakage Post-Esophagogastrectomy for Esophageal Carcinoma: Retrospective Analysis of Predictive Factors, Management and Influence on Long Term Survival in a High Volume Centre,” European Journal of Cardio-Thoracic Surgery 27, no. 1 (2005 January): 3–7.
- 3S. Nusrath, P. Kalluru, S. Shukla, A. Dharanikota, et al, “Current Status of Indocyanine Green Fluorescent Angiography in Assessing Perfusion of Gastric Conduit and Oesophago-Gastric Anastomosis,” International Journal of Surgery (London, England) 110, no. 2 (2024 February 1): 1079–1089.
- 4M. Fabbi, E. R. C. Hagens, M. I. van Berge Henegouwen, and S. S. Gisbertz, “Anastomotic Leakage After Esophagectomy for Esophageal Cancer: Definitions, Diagnostics, and Treatment,” Diseases of the Esophagus 34, no. 1 (2021 January 11): doaa039.
- 5L. Goense, W. A. van Dijk, J. A. Govaert, P. S. N. van Rossum, J. P. Ruurda, and R. van Hillegersberg, “Hospital Costs of Complications After Esophagectomy for Cancer,” European Journal of Surgical Oncology (EJSO) 43, no. 4 (2017 April): 696–702.
- 6E. S. Kassis, A. S. Kosinski, P. Ross, K. E. Koppes, J. M. Donahue, and V. C. Daniel, “Predictors of Anastomotic Leak After Esophagectomy: An Analysis of the Society of Thoracic Surgeons General Thoracic Database,” The Annals of Thoracic Surgery 96, no. 6 (2013 December): 1919–1926.
- 7F. Schlottmann and M. G. Patti, “Evaluation of Gastric Conduit Perfusion During Esophagectomy With Indocyanine Green Fluorescence Imaging,” Journal of Laparoendoscopic & Advanced Surgical Techniques 27, no. 12 (2017 December): 1305–1308.
- 8A. Karliczek, N. J. Harlaar, C. J. Zeebregts, T. Wiggers, P. C. Baas, and G. M. van Dam, “Surgeons Lack Predictive Accuracy for Anastomotic Leakage in Gastrointestinal Surgery,” International Journal of Colorectal Disease 24, no. 5 (2009 May): 569–576.
- 9W. G. Sheridan, R. H. Lowndes, G. T. Williams, and H. L. Young, “Determination of a Critical Level of Tissue Oxygenation in Acute Intestinal Ischaemia,” Gut 33, no. 6 (1992 June): 762–766.
- 10Y. Sakr, “Techniques to Assess Tissue Oxygenation in the Clinical Setting,” Transfusion and Apheresis Science 43, no. 1 (2010): 79–94.
- 11S. R. Thammineedi, S. C. Patnaik, P. Reddy, A. R. Saksena, N. Bollineni, and S. Nusrath, “The Emerging Role of ICG Fluorescence During Minimally Invasive Esophagectomy,” Indian Journal of Surgical Oncology 12, no. 3 (2021 September): 635–636.
- 12H. A. Galema, R. A. Faber, F. P. Tange, et al., “A Quantitative Assessment of Perfusion of the Gastric Conduit After Oesophagectomy Using Near-Infrared Fluorescence With Indocyanine Green,” European Journal of Surgical Oncology 49, no. 5 (2023 May): 990–995.
- 13T. H. Degett, H. S. Andersen, and I. Gögenur, “Indocyanine Green Fluorescence Angiography for Intraoperative Assessment of Gastrointestinal Anastomotic Perfusion: A Systematic Review of Clinical Trials,” Langenbeck's Archives of Surgery 401, no. 6 (2016 September): 767–775.
- 14F. Ladak, J. T. Dang, N. Switzer, et al., “Indocyanine Green for the Prevention of Anastomotic Leaks Following Esophagectomy: A Meta-Analysis,” Surgical Endoscopy 33, no. 2 (2019 February): 384–394.
- 15J. Guo, J. Lu, C. Qiao, and X. Song, “The Value of Indocyanine Green Fluorescence Imaging in Video-Assisted Thoracoscopic Surgery for Esophageal Cancer,” Asian Journal of Surgery 43, no. 11 (2020 November): 1103–1105.
- 16M. D. Slooter, D. M. de Bruin, W. J. Eshuis, et al., “Quantitative Fluorescence-Guided Perfusion Assessment of the Gastric Conduit to Predict Anastomotic Complications After Esophagectomy,” Diseases of the Esophagus 34, no. 5 (2021 May 22): doaa100.
- 17K. Yamaguchi, Y. Kumagai, K. Saito, et al., “The Evaluation of the Gastric Tube Blood Flow by Indocyanine Green Fluorescence Angiography During Esophagectomy: A Multicenter Prospective Study,” General Thoracic and Cardiovascular Surgery 69, no. 7 (2021 July): 1118–1124.
- 18R. T. Subramanyeshwar, K. V. V. N. Raju, S. C. Patnaik, et al., “Minimally Invasive Esophagectomy the Standard of Care: Experience From a Tertiary Care Cancer Center From India,” Indian Journal of Surgical Oncology 12, no. 2 (2021 June): 335–349.
- 19D. E. Low, D. Alderson, I. Cecconello, et al., “International Consensus on Standardization of Data Collection for Complications Associated With Esophagectomy: Esophagectomy Complications Consensus Group (ECCG),” Annals of Surgery 262, no. 2 (2015 August): 286–294.
- 20R. Ortigão, B. Pereira, R. Silva, et al., “Anastomotic Leaks Following Esophagectomy for Esophageal and Gastroesophageal Junction Cancer: The Key Is the Multidisciplinary Management,” GE - Portuguese Journal of Gastroenterology 30, no. 1 (2021 December 14): 38–48.
- 21S. Markar, C. Gronnier, A. Duhamel, et al., “The Impact of Severe Anastomotic Leak on Long-Term Survival and Cancer Recurrence After Surgical Resection for Esophageal Malignancy,” Annals of Surgery 262, no. 6 (2015 December): 972–980.
- 22N. H. Boyle, A. Pearce, D. Hunter, W. J. Owen, and R. C. Mason, “Intraoperative Scanning Laser Doppler Flowmetry in the Assessment of Gastric Tube Perfusion During Esophageal Resection,” Journal of the American College of Surgeons 188, no. 5 (1999 May): 498–502.
- 23Y. Shimada, T. Okumura, T. Nagata, et al., “Usefulness of Blood Supply Visualization by Indocyanine Green Fluorescence for Reconstruction During Esophagectomy,” Esophagus 8, no. 4 (2011 December): 259–266.
- 24Y. Rino, N. Yukawa, T. Sato, et al., “Visualization of Blood Supply Route to the Reconstructed Stomach by Indocyanine Green Fluorescence Imaging During Esophagectomy,” BMC Medical Imaging 14 (2014 May 22): 18.
- 25T. Ishiguro, Y. Kumagai, T. Ono, et al., “Usefulness of Indocyanine Green Angiography for Evaluation of Blood Supply in a Reconstructed Gastric Tube During Esophagectomy,” International Surgery 97, no. 4 (2013 October-December): 340–344.
10.9738/CC159.1 Google Scholar
- 26Y. Kumagai, T. Ishiguro, N. Haga, K. Kuwabara, T. Kawano, and H. Ishida, “Hemodynamics of the Reconstructed Gastric Tube During Esophagectomy: Assessment of Outcomes With Indocyanine Green Fluorescence,” World Journal of Surgery 38, no. 1 (2014 January): 138–143.
- 27S. R. Thammineedi, S. C. Patnaik, A. R. Saksena, P. R. Ramalingam, and S. Nusrath, “The Utility of Indocyanine Green Angiography in the Assessment of Perfusion of Gastric Conduit and Proximal Esophageal Stump Against Visual Assessment in Patients Undergoing Esophagectomy: A Prospective Study,” Indian Journal of Surgical Oncology 11, no. 4 (2020 December): 684–691.
- 28Y. Kumagai, S. Hatano, J. Sobajima, et al., “Indocyanine Green Fluorescence Angiography of the Reconstructed Gastric Tube During Esophagectomy: Efficacy of the 90-second Rule,” Diseases of the Esophagus 31, no. 12 (2018 December 1): doy052, https://doi.org/10.1093/dote/doy052.
- 29R. J. Luo, Z. Y. Zhu, Z. F. He, Y. Xu, Y. Z. Wang, and P. Chen, “Efficacy of Indocyanine Green Fluorescence Angiography in Preventing Anastomotic Leakage After Mckeown Minimally Invasive Esophagectomy,” Frontiers in Oncology 10 (2021 January 8): 619822.
- 30K. Pather, A. M. Deladisma, C. Guerrier, I. R. Kriley, and Z. T. Awad, “Indocyanine Green Perfusion Assessment of the Gastric Conduit in Minimally Invasive Ivor Lewis Esophagectomy,” Surgical Endoscopy 36, no. 2 (2022 February): 896–903.
- 31C. Campbell, M. K. Reames, M. Robinson, J. Symanowski, and J. C. Salo, “Conduit Vascular Evaluation Is Associated With Reduction in Anastomotic Leak After Esophagectomy,” Journal of Gastrointestinal Surgery 19, no. 5 (2015 May): 806–812.
- 32M. D. Slooter, W. J. Eshuis, M. A. Cuesta, S. S. Gisbertz, and M. I. van Berge Henegouwen, “Fluorescent Imaging Using Indocyanine Green During Esophagectomy to Prevent Surgical Morbidity: A Systematic Review and Meta-Analysis,” Journal of Thoracic Disease 11, no. Suppl 5 (2019 April): S755–S765.
- 33J. Zehetner, S. R. DeMeester, E. T. Alicuben, et al., “Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy,” Annals of Surgery 262, no. 1 (2015 July): 74–78.
