Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis

Abstract

Background: Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis.

Methods: This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses.

Results: ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL.

Conclusions: ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion.

Keywords: Colorectal cancer; Double stapling technique; Fluorescence imaging; ICG; Intestinal perfusion.