Use real-time near-infrared fluorescence during Heller's cardiomyotomy for achalasia cardia

Abstract

Laparoscopic Heller's cardiomyotomy is the surgical procedure of choice in the management of oesophageal achalasia. It is critical to confirm the completeness of the myotomy and mucosal integrity at the conclusion of the procedure. This is conventionally achieved by intraoperative endoscopy and dynamic air leak test. Other modalities that can be used to confirm the myotomy and the integrity of the mucosa at the myotomy site are oesophageal manometry and a methylene blue dye study, respectively. Indocyanine green (ICG) has been in clinical use for more than six decades. The real-time integration of ICG fluorescence with laparoscopy is a relatively new breakthrough. Here, we present a novel method of using real-time near-infrared ICG fluorescence for confirming the completeness of the myotomy and mucosal integrity at the myotomy site post laparoscopic Heller's myotomy. This is the first report on the use of ICG in laparoscopic Heller's cardiomyotomy that we are aware of.

Keywords: Achalasia cardia; indocyanine green; intraluminal fluorescence; laparoscopic Heller's cardiomyotomy; mucosal perforation; near-infrared fluorescence.

Figure 1

Real-time near-infrared fluorescence assessment of the myotomy site. Image on the top left shows the laparoscopic view of bulged out mucosa at the cardiomyotomy site, image on the bottom left shows the infrared view of ICG fluorescence and the augmented image is seen in real time on the right side of the panel. Image shows contained fluorescence at the myotomy site confirming the mucosal integrity. ICG: Indocyanine green

Figure 2

Real-time composite image at the completion of the Dor fundoplication. Image on the top left shows the infrared view of ICG fluorescence, image on the right side is the white light traditional laparoscopic view of the bulging mucosa at the lower end of the oesophagus (arrowhead) with separated muscle layers (short arrows), along with a completed Dor fundoplication (long arrow) and image on the bottom left is the real-time augmented image which shows contained uniform fluorescence suggestive of complete myotomy with maintained mucosal integrity. ICG: Indocyanine green