The Grass Is Not Always Greener: Large Scale Study Reveals Indocyanine Green Near-Infrared Visualization During Elective Colorectal Surgeries Is Not Associated With Improved Anastomotic or Oncologic Outcomes

Abstract

IntroductionIndocyanine green (ICG) near-infrared visualization (NIR) is used in colorectal surgery to evaluate anastomotic limb perfusion and aid sentinel lymph node harvest in oncologic surgeries. Proponents of ICG-NIR claim improved anastomotic and oncologic outcomes, but no large-scale studies are reported. This study aims to evaluate the effect of ICG-NIR on anastomotic and oncologic outcomes after colorectal surgeries on a nationwide scale.MethodsRetrospective cohort analysis of the 2016-2020 ACS-NSQIP colorectal-specific database. Adults who underwent elective minimally invasive colorectal surgeries (low anterior resection (LAR), partial colectomy (PC), or right colectomy (RC)) were stratified into 2 groups based on intraoperative ICG-NIR use. Outcomes measured were operative duration, anastomotic leak, unplanned conversion to open, return to the operating room, perioperative bleeding requiring blood transfusions, survivor-only length of stay (LOS), mortality, and unplanned readmissions. Sub-analysis of lymph node harvest and margin-positive status was performed among patients with colorectal cancer.Results95 179 patients were identified (ICG-NIR: 1101 (1.2%); No ICG-NIR: 94 078 (98.8%). There were no differences in 30-day outcomes between groups except for longer OR duration among ICG-NIR group. ICG-NIR was not independently associated with reduced adjusted odds of anastomotic leak (aOR 0.790 (95% CI 0.520-1.201), P = 0.270). There were no differences between subgroups in terms of lymph node harvest or resection margin positive status.ConclusionThis is a large nationwide study showing leak rates and oncologic outcomes do not improve with ICG-NIR. The utility of ICG-NIR over preoperative bowel preparation, surgical technique, and gross visualization may be overstated warranting further study.

Keywords: ICG near-infrared visualization; colorectal surgery; elective surgery; outcomes.