Does routine use of indocyanine green fluorescence angiography prevent anastomotic leaks? A retrospective cohort analysis.

BACKGROUND: Insufficient perfusion to anastomoses in colorectal surgery is known to lead to complications. This study aims to evaluate whether routine use of fluorescence angiography (FA) alters the incidence of anastomotic leaks after colorectal surgery. METHODS: This was a retrospective study of 554 colorectal resections with and without the use of intraoperative fluorescence angiography. Anastomotic leak rates and whether angiography altered surgical management were the main outcomes measured. RESULTS: The anastomotic leak rate was found to be 1.3% both with and without use of FA (p > 0.05). Significantly more alterations were made to planned anastomotic site in FA group (n = 13, 5.6%) as compared to the group prior to use of FA in whom no alterations were made (p < 0.05). CONCLUSIONS: No significant difference was found in anastomotic leak rates between the two groups studied. Routine use of fluorescence angiography significantly altered intra-operative decision-making without discernible change in clinical outcome.

Intraoperative indocyanine green fluorescence angiography--an objective evaluation of anastomotic perfusion in colorectal surgery.

The essentials for any bowel anastomosis are: adequate perfusion, tension free, accurate tissue apposition, and minimal local spillage. Traditionally, perfusion is measured by assessing palpable pulses in the mesentery, active bleeding at cut edges, and lack of tissue discoloration. However, subjective methods lack predictive accuracy for an anastomotic leak. We used intraoperative indocyanine green (ICG) fluorescence angiography to objectively assess colon perfusion before a bowel anastomosis. Seventy-seven laparoscopic colorectal operations, between June 2013 and June 2014, were retrospectively reviewed. The perfusion to the colon and ileum was clinically assessed, and then measured using the SPY Elite Imaging System. The absolute value provided an objective number on a 0-256 gray-scale to represent differences in ICG fluorescence intensity. The lowest absolute value was used in data analysis for each anastomosis (including small bowel) to represent the theoretical least perfused/weakest anastomotic area. The lowest absolute value recorded was 20 in a patient who underwent a laparoscopic right hemicolectomy for an adenoma, with no postoperative complications. Four low anterior resection patients had additional segments of descending colon resected. There was one mortality in a patient who underwent a laparoscopic right hemicolectomy. This study illustrates an initial experience with the SPY system in colorectal surgery. The SPY provides an objective, numerical value of bowel perfusion. However, evidence is scant as to the significance of these numbers. Large-scale randomized controlled trials are required to determine specific cutoff values correlated with surgical outcomes, specifically anastomotic leak rates.

Laparoscopic repair of a free perforation of a marginal ulcer after Roux-en-Y gastric bypass: a safe alternative to open exploration.

OBJECTIVES: We present 2 patients with free perforation of the anterior wall of the Roux limb due to marginal ulceration after an antecolic laparoscopic gastric bypass and describe the surgical management and laparoscopic repair technique. METHODS: A 15 mm Hg pneumoperitoneum was established with a Veress needle via the left subcostal approach in both patients. Entrance into the abdomen was achieved with the 5 mm Optiview blunt trocar. The Genzyme liver retractor was used to lift the left lobe of the liver and expose the gastrojejunal anastomosis. A 30 degrees 5 mm telescope was used for visualization. In both cases, free fluid and purulent material were noted in the subdiaphragmatic region and along the right paracolic gutter, but the gastrojejunal anastomoses was intact. A 1 cm perforation with surrounding inflammatory exudate was identified on the anterior surface of the Roux limb distal to the gastrojejunostomy. The edges were debrided and intracorporeal 1-layer repair of the ulcer was performed with simple interrupted 2-0 Vicryl sutures. Fibrin glue was applied to the suture line and covered with an omental onlay patch. The anastomosis was tested with air insufflation and methylene blue dye with no evidence of a leak. A Jackson-Pratt drain was placed in the left upper quadrant. RESULTS: Both patients underwent an unremarkable hospital course, and follow-up EGD examination after 3 months revealed no evidence of ulceration. CONCLUSION: Laparoscopic exploration and the repair of the gastrointestinal perforations in patients with a recent history of laparoscopic RYGBP is safe, if patients are hemodynamically stable and present within the first 24 hours of the onset of symptoms.