Role of indocyanine green to look for vascularity of the pancreatic stump during Whipple's procedure and its clinical implications in terms of post-pancreatectomy acute pancreatitis and postoperative pancreatic fistula

Abstract

Objectives: Post-pancreatectomy acute pancreatitis (PPAP) has been a well-defined entity by the International Study Group of Pancreatic Surgery. Underlying cause may be hypoperfusion at remnant stump of pancreas, which has been linked with additional post-pancreatectomy complications like postoperative pancreatic fistula. The primary goal was to assess the vascularity of remnant pancreas utilizing indocyanine green with near-infrared fluorescence. Indocyanine Green could aid in objectively mitigating hypoperfusion status of the pancreatic stump.

Design: Hospital-based descriptive study conducted as per the revised Strengthening the Reporting of Observational Studies in Epidemiology guidelines between 1 August 2022 and 2 August 2023.

Setting: This study was conducted in tertiary care centers of Kathmandu.

Participants: All 43 participants who underwent pancreaticoduodenectomies were included who completed the study.

Intervention: Blood supply to the remnant of the pancreas during pancreaticoduodenectomy was assessed utilizing indocyanine green, capturing distinct arterial, venous, and port venous phases, which were analyzed after 10 to 15 s of administration.

Main outcome measures: In three instances, indocyanine green dye revealed unequal vascular supply at the pancreatic remnant, requiring adjustments to the margins before completing the anastomosis of the remnant pancreas and the jejunum.

Results: PPAP was noticed in eight patients (18.6%), among which five patients (11.6 %) had postoperative hyperamylasemia, and three had grade B PPAP. The outcomes revealed that in the 40 patients with adequate perfusion, PPAP occurred in seven patients(16.3%), and grade B clinically relevant postoperative pancreatic fistula occurred in one patient. In contrast, among the three patients with inadequate perfusion, after revision of the pancreatic margin, PPAP was observed in one patient, and none of them had clinically relevant post-operative pancreatic fistula.

Conclusion: Postoperative acute pancreatitis, ultimately exhibiting the possibility of postoperative pancreatic fistula, must be monitored with vigilance. While several elements contribute to fistula formation, ensuring sufficient vascular supply at the pancreatic remnant using indocyanine green may alleviate presumed PPAP and associated complications. The dye could aid in enhancing surgical outcomes following pancreaticoduodenectomy.

Keywords: Health Technology; Laparoscopy.

Figure 1. ICG NIR imaging phases: A, arterial phase showing the hepatic artery; B, pancreatic phase showing the pancreas with heterogeneous uptake of the resected margin; and C, porto-venous phase. ICG, indocyanine green; NIR, near-infrared.

Figure 2. Pancreatic stump margin showing absent ICG uptake. ICG, indocyanine green.

Figure 3. Heterogeneous ICG uptake of pancreatic stump. ICG, indocyanine green.

Figure 4. Pancreatic stump margin showing adequate perfusion.