Author: fidelmac

Adequate distal skin paddle perfusion is essential to preventing postoperative flap necrosis in head and neck reconstruction. A retrospective cohort study consistently of patients who underwent head and neck reconstruction with a supraclavicular artery island flap for any indication at a tertiary medical center from 2010 to 2018. The predictor variable was ICGA use. The primary outcome was rate of skin paddle necrosis. Secondary outcomes included rates of post-operative overall complications, dehiscence, fistula, and reoperation. Covariates included demographic, operative, flap perfusion assessment, and postoperative variables. Retrospective assessment of distal flap perfusion was performed on available ICGA video recordings. Descriptive and bivariate statistics were computed. Statistical significance was set at P ≤ .05.

Results: A total of 104 patients were included and ICGA was used in 23 cases. In 10 of these cases, flap trimming was performed due to concern of flap hypoperfusion on ICGA. The median relative distal flap perfusion was 16.7 ± 2.6% in trimmed flaps, compared to 35 ± 13.2% in untrimmed flaps. ICGA use was not associated with rate of skin paddle necrosis (P = .76).

Conclusions: ICGA is a viable method of assessing intraoperative supraclavicular artery island skin paddle perfusion and can help determine the need for distal flap trimming when tissue viability based on clinical findings alone is uncertain. ICGA use for skin paddles with uncertain perfusion on intraoperative clinical findings prevented a potential increase in postoperative necrosis compared to that of skin paddles with adequate perfusion on intraoperative clinical findings. Future studies are required to determine the minimum distal perfusion value that indicates hypoperfusion and the need for flap modification.

https://pubmed.ncbi.nlm.nih.gov/35605670/

Background: In rectal cancer surgery, anastomotic leakage (AL) remains the most feared complication, with a frequency of up to 30% in non-high-volume centers. The preservation of proper vascularization is a key factor for successful anastomosis. The use of fluorescence with indocyanine green (ICG) as an intraoperative method to verify optimal perfusion is becoming an interesting tool in rectal surgery.
Today, robotic surgery, together with the use of the intraoperative evaluation of the perfusion with ICG, could be a real strategy to deal with AL, allowing for a more delicate and less traumatic surgical technique. This strategy may allow for an extremely accurate surgery, and for optimal control of the proper vascularization of the rectum. We performed a systematic literature search using the PubMed, Embase and Cochrane library databases.

Conclusions: ICG fluorescence is an inexpensive and quick method to assess bowel perfusion, providing immediate feedback to the surgeon.

https://pubmed.ncbi.nlm.nih.gov/35626015/

Re-operation due to disease being inadvertently close to the resection margin is a major challenge in breast conserving surgery (BCS). Indocyanine green (ICG) fluorescence imaging could be used to visualize the tumor boundaries and help surgeons resect disease more efficiently. In this work, ICG fluorescence and color images were acquired with a custom-built camera system from 40 patients treated with BCS. Images were acquired from the tumor in-situ, surgical cavity post-excision, freshly excised tumor and histopathology tumour grossing.

Fluorescence image intensity and texture were used as individual or combined predictors in both logistic regression (LR) and support vector machine models to predict the tumor extent. ICG fluorescence spectra in formalin-fixed histopathology grossing tumor were acquired and analyzed. Our results showed that ICG remains in the tissue after formalin fixation.

Therefore, tissue imaging could be validated in freshly excised and in formalin-fixed grossing tumor. The trained LR model with combined fluorescence intensity (pixel values) and texture (slope of power spectral density curve) identified the tumor’s extent in the grossing images with pixel-level resolution and sensitivity, specificity of 0.75 ± 0.3, 0.89 ± 0.2.This model was applied on tumor in-situ and surgical cavity (post-excision) images to predict tumor presence.

https://pubmed.ncbi.nlm.nih.gov/35597783/

Ultrasound, computed tomographic peritoneography, methylene blue, and peritoneal scintigraphy are commonly used to identify peritoneal dialysis-related complications in clinical settings. This study aimed to investigate the diagnostic value of indocyanine green in peritoneal dialysis-related complications and to study the effect of indocyanine green on residual renal function and peritoneal function.

Methods: Twenty male Sprague-Dawley rats were used to establish models, including a pleural effusion model (A, n=4), abdominal hernia model (B, n=4), subcutaneous leakage model (C, n=4), and control (D, n=8). They were injected with a 20 mL mixture of peritoneal dialysate and indocyanine green at varying concentrations prepared for near-infrared fluorescence imaging. We compared the results of near-infrared-I and near-infrared-II imaging. Radiologists evaluated the image quality, morphology, and thickness of the peritoneum, and the residual renal function was assessed using haematoxylin and eosin staining.

Conclusion: Near-infrared-I fluorescence imaging of ICG has a better SBR than near-infrared-II and it is sufficient for diagnosing peritoneal dialysis-related complications and ICG has no impact on residual renal function and peritoneal function. This method has clinical application potential in promptly diagnosing peritoneal dialysis-related complications.

https://pubmed.ncbi.nlm.nih.gov/35545201/

The staple line gastric leak (GL) is estimated to be the most serious complication of the sleeve gastrectomy. The use of indocyanine green (ICG) has been introduced in minimally invasive surgery to show the vascularization of the stomach in real time and its application to the gastroesophageal junction (GE) during Laparoscopic Sleeve Gastrectomy (LSG) seems very promising. We present the case of a 40-year-old female underwent laparoscopic sleeve gastrectomy. Intraoperative indocyanine green test showed a small dark area in the proximal third of the staple line reinforced with fibrin glue.

Two weeks later the patient presented to the emergency room (ED) with abdominal pain, fever, vomiting, intolerance to oral intake and the evidence of a leak on the abdomen Computer Tomography (CT). This case report shows that intraoperative ICG test can be helpful in determining which patients are at greater risk of the leak and, more importantly, the cause of the leak but further tests are needed to determine if the ICG predicts leak due to ischemia.

https://www.sciencedirect.com/science/article/pii/S221026122200414X?via%3Dihub

Surgery remains the only curative treatment for rectal cancer, despite the progress in oncological therapies. The widespread use of robotic surgery drastically changed the approach to rectal cancer, reducing the burden of the procedure on the patient’s quality of life and allowing a faster recovery. Indocyanine green fluorescence has shown promising results in reducing severe surgical complications, such as anastomotic leak, that can delay the beginning of further chemo-radio treatments. The purpose of this descriptive review is to analyze the impact of indocyanine green fluorescence when applied in robotic surgery on short-term surgical outcomes for rectal cancer, providing a picture of the current literature on the issue, highlighting the heterogeneity of protocols and focusing on possible future development.

In rectal cancer surgery, anastomotic leakage (AL) remains the most feared complication, with a frequency of up to 30% in non-high-volume centers. The preservation of proper vascularization is a key factor for successful anastomosis. The use of fluorescence with indocyanine green (ICG) as an intraoperative method to verify optimal perfusion is becoming an interesting tool in rectal surgery. Today, robotic surgery, together with the use of the intraoperative evaluation of the perfusion with ICG, could be a real strategy to deal with AL, allowing for a more delicate and less traumatic surgical technique. This strategy may allow for an extremely accurate surgery, and for optimal control of the proper vascularization of the rectum.

Methods: The purpose of this descriptive review is to analyze the impact of fluorescence and robotic surgery on short-term surgical outcomes for rectal cancer.

Results: We performed a systematic literature search using the PubMed, Embase and Cochrane library databases. The primary endpoints were to evaluate the application of ICG fluorescence in robotic rectal surgery and the rate of anastomotic leakage when using these technological implementations. The secondary endpoints were to evaluate the dosage of ICG and the timing of application by different surgeons. Conclusions: ICG fluorescence is an inexpensive and quick method to assess bowel perfusion, providing immediate feedback to the surgeon…

https://www.mdpi.com/2072-6694/14/10/2411

Introduction: Indocyanine green fluorescence angiography (ICGFA) is commonly used in colorectal anastomotic practice with limited pre-training. Recent work has shown that there is considerable inconsistency in signal interpretation between surgeons with minimal or no experience versus those consciously invested in mastery of the technique. Here, we deconstruct the fluorescence signal patterns of expert-annotated surgical ICGFA videos to understand better their correlation and combine this with structured interviews to ascertain whether such interpretative capability is conscious or unconscious.

Methods: For fluorescence signal analysis, expert-annotated ICGFA videos (n = 24) were quantitatively interrogated using a boutique intensity tracker (IBM Research) to generate signal time plots. Such fluorescence intensity data were examined for inter-observer correlation (Intraclass Correlation Coefficients, ICC) at specific curve milestones: the maximum fluorescence signal (Fmax), the times to both achieve this maximum (Tmax), as well as half this maximum (T1/2max) and the ratio between these (T1/2/Tmax). Formal tele-interview with contributing experts (n = 6) was conducted with the narrative transcripts being thematically mapped, plotted, and qualitatively analysed.

Results: Correlation by mathematical measures was excellent (ICC0.9-1.0) for Fmax, Tmax, and T1/2max (0.95, 0.938, and 0.925, respectively) and moderate (0.5-0.75) for T1/2/Tmax (0.729). While all experts narrated a deliberate viewing strategy, their specific dynamic signal appreciation differed in the manner of description.

Conclusion: Expert ICGFA users demonstrate high correlation in mathematical measures of their signal interpretation although do so tacitly. Computational quantification of expert behaviour can help develop the necessary lexicon and training sets as well as computer vision methodology to better exploit ICGFA technology.

https://pubmed.ncbi.nlm.nih.gov/35543771/

Bronchopleural fistula (BPF) following lung resection and thoracic surgery is associated with high rates of morbidity and mortality. Various methods are available for the closure of BPF and thoracic dead space, including flap procedures and thoracoplasty. While delayed random flaps have been used for the treatment of BPF and closure of thoracic dead space, no previous reports have described the concurrent use of laser-assisted indocyanine green angiography (ICG-A). We report a case of successful BPF closure with a random delayed fasciocutaneous flap using laser-assisted ICG-A guidance for flap delay. In conclusion, this case report describes for the first time the successful management of a post-lobectomy BPF using both a delayed flap technique and assessment under ICG guidance. This management technique should be further studied and standardized for use in other patient cases in hopes of minimizing morbidity and mortality from complex cases of BPFs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9053379/

Transthoracic esophagectomy is a highly complex and sophisticated procedure with high morbidity rates and a significant mortality. Surgical access has consistently become less invasive, transitioning from open esophagectomy to hybrid esophagectomy (HE) then to totally minimally invasive esophagectomy (MIE), and most recently to robot-assisted minimally invasive esophagectomy (RAMIE), with each step demonstrating improved patient outcomes. Aim of this study with more than 600 patients is to complete a propensity-score matched comparison of postoperative short-term outcomes after highly standardized RAMIE vs. HE in a European high volume center. Six hundred and eleven patients that underwent transthoracic Ivor-Lewis esophagectomy for esophageal cancer between May 2016 and May 2021 were included in the study. In January 2019, we implemented an updated robotic standardized anastomotic technique using a circular stapler and ICG (indocyanine green) for RAMIE cases.

Data were retrospectively analyzed from a prospectively maintained IRB-approved database. Outcomes of patients undergoing standardized RAMIE from January 2019 to May 2021 were compared to our overall cohort from May 2016-April 2021 (HE) after a propensity-score matching analysis was performed. Our analysis confirms the safety and feasibility of RAMIE and HE in a large cohort after propensity score matching. A regular postoperative course (Clavien-Dindo 0) and a shorter ICU stay were seen significantly more often after RAMIE compared to HE.

https://pubmed.ncbi.nlm.nih.gov/35505259/