Optimizing quantitative fluorescence angiography for visceral perfusion assessment

Abstract Background Anastomotic leakage (AL) after gastrointestinal resection is a devastating complication with huge consequences for the patient. As AL is associated with poor blood supply, tools for objective assessment of perfusion are in high demand. Indocyanine green angiography (ICG-FA) and quantitative analysis of ICG-FA (q-ICG) seem promising. This study aimed to investigate whether ICG-FA and q-ICG could improve perfusion assessment performed by surgeons of different experience levels. Methods Thirteen small bowel segments with a varying degree of devascularization, including two healthy sham segments, were constructed in a porcine model. We recruited students, residents, and surgeons to perform perfusion assessment of the segments in white light (WL), with ICG-FA, and after q-ICG, all blinded to the degree of devascularization. Results Forty-five participants fulfilled the study (18 novices, 12 intermediates, and 15 experienced). ICG and q-ICG helped the novices correctly detect the healthy bowel segments to experienced surgeons’ level. ICG and q-ICG also helped novice surgeons to perform safer resections in healthy tissue compared with normal WL. The relative risk (RR) of leaving ischemic tissue in WL and ICG compared with q-ICG, even for experienced surgeons was substantial, intermediates (RR = 8.9, CI95% [4.0;20] and RR = 6.2, CI95% [2.7;14.1]), and experienced (RR = 4.7, CI95% [2.6;8.7] and RR = 4.0, CI95% [2.1;7.5]). Conclusion Q-ICG seems to guide surgeons, regardless of experience level, to safely perform resection in healthy tissue, compared with standard WL. Future research should focus on this novel tool’s clinical impact.

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Laser speckle contrast imaging and quantitative fluorescence angiography for perfusion assessment

Langenbeck s Archives of Surgery ◽

10.1007/s00423-019-01789-8 ◽

2019 ◽

Vol 404 (4) ◽

pp. 505-515 ◽

Cited By ~ 7

Author(s):

Jonas Hedelund Rønn ◽

Nikolaj Nerup ◽

Rune Broni Strandby ◽

Morten Bo Søndergaard Svendsen ◽

Rikard Ambrus ◽

...

Keyword(s):

Laser Speckle ◽

Fluorescence Angiography ◽

Contrast Imaging ◽

Laser Speckle Contrast Imaging ◽

Speckle Contrast ◽

Perfusion Assessment ◽

Quantitative Fluorescence

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663 QUANTITATIVE PERFUSION ASSESSMENT TO PREDICT ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY

Diseases of the Esophagus ◽

10.1093/dote/doab052.663 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Yoshitaka Ishikawa ◽

Christopher Breuler ◽

Andrew C Chang ◽

Jules Lin ◽

Mark B Orringer ◽

...

Keyword(s):

Anastomotic Leak ◽

Anastomotic Stricture ◽

Statistical Significance ◽

Multivariable Analysis ◽

Gastric Conduit ◽

Fluorescence Angiography ◽

Operative Care ◽

Significant Difference ◽

Perfusion Assessment ◽

Mckeown Esophagectomy

Abstract Impaired gastric conduit perfusion is a risk factor for anastomotic leak after esophagectomy. Most studies evaluating conduit perfusion have been qualitative with limited impact on post-operative care. The aim of this study is to evaluate the feasibility of intraoperative quantitative assessment of gastric conduit perfusion with indocyanine green (ICG) fluorescence angiography as a predictor for cervical esophagogastric anastomotic (CEGA) leak after esophagectomy. Methods ICG fluorescence angiography using the SPY elite® (Stryker, MI, USA) system was performed in patients who had undergone a transhiatal or McKeown esophagectomy CEGA from July 2015 through December 2020. Fluorescence angiography assessed Ingress (dye uptake) and Egress (dye exit). Ingress Index, Ingress Time, Egress Index, and Egress Time at two anatomic landmarks (tip of the conduit, and 5 cm from tip) were calculated from the measured curve of fluorescence (Figure). The collected data between the leak (L) group and the no-leak (NL) group were compared by both univariate and multivariable analyses to analyze risk factors potentially associated with CEGA leak. Results 304 patients were evaluated. There was no significant difference in patients' demographic and post-operative complications between the groups (L n = 73; NL n = 231), except for anastomotic stricture (42.5 vs 9.1%, p < 0.01). 5 cm and Tip Ingress Index were significantly lower in L (35.0 vs 45.1% and 17.4 vs 25.7%, p < 0.01). 5 cm Ingress Time was significantly higher in L (70.6 vs 56.8 sec, p < 0.01). On multivariable analysis, these variables retained statistical significance, suggesting that these three variables can be used to predict future leak. Conclusion This study revealed that gastric conduit perfusion correlates with the incidence of CEGA leak. Intraoperative measurement of gastric conduit perfusion may be predictive for CEGA leak following esophagectomy. These variables can be easily collected intraoperatively with the SPY study and used to make clinical decisions which may avert CEGA leak.

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Intestinal perfusion assessed by quantitative fluorescence angiography in piglets with necrotizing enterocolitis

Journal of Pediatric Surgery ◽

10.1016/j.jpedsurg.2021.10.021 ◽

2021 ◽

Author(s):

Kristine Bach Korsholm Knudsen ◽

Nikolaj Nerup ◽

Joergen Thorup ◽

Thomas Thymann ◽

Per Torp Sangild ◽

...

Keyword(s):

Necrotizing Enterocolitis ◽

Intestinal Perfusion ◽

Fluorescence Angiography ◽

Quantitative Fluorescence

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P5 FEASIBILITY AND EFFICACY OF INDOCYANINE GREEN ANGIOGRAPHY DURING ESOPHAGECTOMY: A SYSTEMATIC REVIEW

Diseases of the Esophagus ◽

10.1093/dote/doz092.05 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Van Daele Elke ◽

Vanommeslaeghe Hanne ◽

Van Nieuwenhove Yves ◽

Ceelen Wim ◽

Vanhove Christian ◽

...

Keyword(s):

Indocyanine Green ◽

Indocyanine Green Angiography ◽

Assessment Tool ◽

Fluorescence Angiography ◽

Control Group ◽

High Morbidity ◽

Easy Method ◽

Nirf Imaging ◽

Perfusion Assessment ◽

The Impact

Abstract Aim The aim of this review was to evaluate feasibility and effectiveness of Indocyanine green fluorescence angiography (ICGA) as an assessment tool for gastric tube (GT) perfusion during the construction of the esophago-gastric anastomosis, and as a predictor of anastomotic leakage (AL). Moreover, attention was given to attempts made to quantify this method in esophageal surgery. Background & Methods After an esophagectomy, a GT is most commonly used to restore continuity of the upper gastrointestinal tract. Esophago-gastric anastomoses are known for their complications such as AL, associated with high morbidity and mortality. Graft perfusion is an important predictor for anastomotic integrity. Tissue perfusion assessment is currently based on subjective parameters as tissue color and vessel pulsations. Near infrared fluorescent (NIRF) imaging is an emerging medical imaging modality, requiring penetrating NIR light that excites a NIRF agent within the tissue, generating fluorescence that can then be captured by adapted cameras. Indocyanine green Angiography (ICGA) is such a NIRF imaging technique which can be used as a method to visualize anastomotic perfusion. For this review, 2 reviewers independently searched Pubmed and Embase for studies evaluating intraoperative ICGA perfusion assessment of the GT. Feasibility, complications, intraoperative surgical changes based on ICGA findings, quantification attempts, anatomical data and the impact of ICGA on postoperative anastomotic complications were documented and further analyzed. Results Nineteen studies were included for qualitative analyses. All described ICGA as a safe and easy method for gastric graft perfusion assessment. AL occurred in 13.8% of the entire cohort, 10% in the ICG guided group and 20.6% in the control group (p<.001). AL in the well-perfused group was 6.3% vs. 20.5% in the control group without ICGA (p< .001). The group with an altered surgical plan based on the ICG image had similar AL rates as the well perfused group (6.5% vs. 6.3%) and significantly less than the poorly perfused group (47.8%) (p<.001), suggesting that the technique is able to identify and alter a potential bad outcome. Conclusion the present review suggest that ICGA is a safe and easy method for GT perfusion assessment. Differences in AL rate between the well perfused and poor perfused anastomotic sites suggest that a good fluorescent signal is a predictor of good outcome.

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Quantitative cerebral perfusion assessment using microscope-integrated analysis of intraoperative indocyanine green fluorescence angiography versus positron emission tomography in superficial temporal artery to middle cerebral artery anastomosis

Surgical Neurology International ◽

10.4103/2152-7806.140705 ◽

2014 ◽

Vol 5 (1) ◽

pp. 135 ◽

Cited By ~ 11

Author(s):

Shinya Kobayashi ◽

Tatsuya Ishikawa ◽

Jun Tanabe ◽

Junta Moroi ◽

Akifumi Suzuki

Keyword(s):

Superficial Temporal Artery ◽

Temporal Artery ◽

Emission Tomography ◽

Fluorescence Angiography ◽

Integrated Analysis ◽

Green Fluorescence ◽

Indocyanine Green Fluorescence ◽

Positron Emission ◽

Perfusion Assessment ◽

Indocyanine Green Fluorescence Angiography

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Quantitative fluorescence angiography detects dynamic changes in gastric perfusion

Surgical Endoscopy ◽

10.1007/s00464-020-08183-2 ◽

2020 ◽

Author(s):

Jens Osterkamp ◽

Rune Strandby ◽

Nikolaj Nerup ◽

Morten Svendsen ◽

Lars Svendsen ◽

...

Keyword(s):

Fluorescence Angiography ◽

Dynamic Changes ◽

Quantitative Fluorescence

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Comparison of Optical Imaging Techniques to Quantitatively Assess the Perfusion of the Gastric Conduit during Oesophagectomy

Applied Sciences ◽

10.3390/app10165522 ◽

2020 ◽

Vol 10 (16) ◽

pp. 5522

Author(s):

Maxime D. Slooter ◽

Sanne M. A. Jansen ◽

Paul R. Bloemen ◽

Richard M. van den Elzen ◽

Leah S. Wilk ◽

...

Keyword(s):

Optical Imaging ◽

Anastomotic Leakage ◽

Imaging Techniques ◽

Gastric Conduit ◽

Laser Speckle ◽

Fluorescence Angiography ◽

Optical Techniques ◽

Quantitative Perfusion ◽

Quantitative Parameters ◽

Perfusion Assessment

In this study, four optical techniques—Optical Coherence Tomography, Sidestream Darkfield Microscopy, Laser Speckle Contrast Imaging, and Fluorescence Angiography (FA)—were compared on performing an intraoperative quantitative perfusion assessment of the gastric conduit during oesophagectomy. We hypothesised that the quantitative parameters show decreased perfusion towards the fundus in the gastric conduit and in patients with anastomotic leakage. In a prospective study in patients undergoing oesophagectomy with gastric conduit reconstruction, measurements were taken with all four optical techniques at four locations from the base towards the fundus in the gastric conduit (Loc1, Loc2, Loc3, Loc4). The primary outcome included 14 quantitative parameters and the anastomotic leakage rate. Imaging was performed in 22 patients during oesophagectomy. Ten out of 14 quantitative parameters significantly indicated a reduced perfusion towards the fundus of the gastric conduit. Anastomotic leakage occurred in 4/22 patients (18.4%). At Loc4, the FA quantitative values for “T1/2” and “mean slope” differed between patients with and without anastomotic leakage (p = 0.025 and p = 0.041, respectively). A quantitative perfusion assessment during oesophagectomy is feasible using optical imaging techniques, of which FA is the most promising for future research.

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Quantitative fluorescence-guided perfusion assessment of the gastric conduit to predict anastomotic complications after esophagectomy

Diseases of the Esophagus ◽

10.1093/dote/doaa100 ◽

2020 ◽

Author(s):

M D Slooter ◽

D M de Bruin ◽

W J Eshuis ◽

D P Veelo ◽

S van Dieren ◽

...

Keyword(s):

Anastomotic Leakage ◽

Anastomotic Stricture ◽

Area Under The Curve ◽

Gastric Conduit ◽

Fluorescence Angiography ◽

Anastomotic Site ◽

Anastomotic Complications ◽

Risk Patients ◽

Perfusion Assessment

Summary Background: Fluorescence angiography (FA) assesses anastomotic perfusion during esophagectomy with gastric conduit reconstruction, but its interpretation is subjective. This study evaluated time to fluorescent enhancement in the gastric conduit, with the aim to determine a threshold to predict postoperative anastomotic complications. Methods: In a prospective cohort study, all consecutive patients undergoing esophagectomy with gastric conduit reconstruction from July 2018 to October 2019 were included. FA was performed before anastomotic reconstruction following injection of indocyanine green (ICG). During FA, the following time points were recorded: ICG injection, first fluorescent enhancement in the lung, at the base of the gastric conduit, at the planned anastomotic site, and at ICG watershed or in the tip of the gastric conduit. Anastomotic complications including anastomotic leakage and clinically relevant strictures were documented. Results: Eighty-four patients were included, the majority (67 out of 84, 80%) of which underwent an Ivor Lewis procedure. After a median follow-up of 297 days, anastomotic leakage was observed in 12 out of 84 (14.3%) and anastomotic stricture in 12 out of 82 (14.6%). Time between ICG injection and enhancement in the tip was predictive for anastomotic leakage (P = 0.174, area under the curve = 0.731), and a cut-off value of 98 seconds was derived (specificity: 98%). All times to enhancement at the planned anastomotic site and ICG watershed were significantly predictive for the occurrence of a stricture, however area under the curves were <0.7. Conclusions: The identified fluorescent threshold can be used for intraoperative decision making or to identify potentially high-risk patients for anastomotic leakage after esophagectomy with gastric conduit reconstruction.

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