Author: fidelmac

Retinal arterial macroaneurysms represent an acquired vascular irregularity that is primarily observed in the elderly population. The high variability surrounding the clinical presentation of this condition makes the initial diagnosis challenging. Employing several diagnostic techniques including fundus fluorescence angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography ensures that any hemorrhages secondary to macroaneurysms rupture are identified promptly.

Diagnosis of retinal arterial macroaneurysm must be confirmed by complimenting clinical examination with imaging techniques such as FFA, OCT, and indocyanine green angiography (ICGA)….It is recommended to conduct indocyanine green angiography (ICGA) in cases where the nature of macroaneurysm cannot be confirmed because of the obscurity of hemorrhage. RAMs show well-defined areas of hyper fluorescence with ICG angiography and ICG can pinpoint the exact location of the macroaneurysm in cases of dense hemorrhage, which may be useful in planning surgery or treatment .

This is crucial for appropriately managing the case and ensuring a good prognosis. 

https://www.cureus.com/articles/89147-multilayered-hemorrhage-secondary-to-retinal-arterial-macroaneurysm-rupture-a-case-report-and-review-of-literature

The use of skin flaps to fill large defects is a key surgical technique in reconstructive surgery, effective real-time in vivo imaging for flap design and use is urgent. Currently, fluorescent imaging in the second NIR window (NIR-II; 1000-1700 nm) is characterized by non-radiation, less expensive and higher resolution in comparisons with the first NIR window (NIR-I; 700-900 nm) and other traditional imaging modalities. In this article, we identified the location and numbers of perforators and choke zone via NIR-II imaging. Then, eight abdominal perforator flaps were established and evaluated the perfusion zones at special time points.

Finally, after eight pedicled flaps establishment, NIR-II imaging was used to guide the optimal timing for division of flap pedicle. The results showed that NIR-II fluorescence imaging with indocyanine green (ICG) can reliably visualize vascular supply, which makes it to be an accurate and in vivo imaging approach to flap clinical design and use. 

https://pubmed.ncbi.nlm.nih.gov/35474297/

Background: We describe the technical operative details of the robotic repair of a type II endoleak (T2E) following endovascular abdominal aortic aneurysm repair (EVAR). We demonstrate that indocyanine green (ICG) can be used intra-operatively to demonstrate perfusion of the colon following ligation of the inferior mesenteric artery (IMA) vessel feeding the aneurysm sac.

Methods: A 74-year old male underwent EVAR for a 5.8 cm infra-renal abdominal aortic aneurysm using an E-Tegra, Jotec Device (JOTEC Gmb, Lotzenäcker 23,D-72379 Hechingen). Surveillance contrast CT (CTA) over the ensuing 30 months confirmed progressive sac expansion.

Results: ICG confirmed colonic perfusion via the marginals after IMA ligation. Total operative time 56 min < 50 mls blood loss and 1-day hospital stay. 3-month follow-up: CTA and ultrasound demonstrated complete resolution of T2E and adequately perfused colon.

Conclusion: A total robotic approach can be performed safely with intra-operative ICG used to demonstrate colonic perfusion as an added safety measure.

https://pubmed.ncbi.nlm.nih.gov/35441796/

Background: Near-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized. This survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons. Survey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P < .001).Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption.

Conclusions: NIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption.

https://pubmed.ncbi.nlm.nih.gov/35451339/

To evaluate whether visualization of the colon perfusion with indocyanine green near-infrared fluoroangiography (ICG-NIFA) reduces the rate of anastomotic leakage (AL) after colorectal anastomosis.

Methods: Patients who underwent elective left colectomy, including all procedures involving the sigmoid colon and the rectum with a colorectal or coloanal anastomosis, were retrospectively analyzed for their demographics, operative details, and the rate of AL. Univariate and multivariate analyses were used to compare patients with and without ICG-NIFA-based evaluation.

Results: Overall, our study included 132 colorectal resections [70 sigmoid resections and 62 total mesorectal excisions (TMEs)], of which 70 (53%) were performed with and 62 (47%) without ICG-NIFA. Patients’ characteristics were similar between both the groups. The majority of the procedures [91 (69%)] were performed by certified colorectal surgeons, while 41 (31%) operations were supervised teaching procedures. In the ICG-NIFA group, bowel perfusion could be visualized by fluorescence (dye) in all 70 cases, and no adverse effects related to the fluorescent dye were observed. Following ICG-NIFA, the transection line was changed in 9 (12.9%) cases. Overall, 10 (7.6%) patients developed AL, 1 (1.4%) in the ICG-NIFA group and 9 (14.5%) in the no-ICG-NIFA group (p = 0.006). The multivariate analysis revealed ICG-NIFA as an independent factor to reduce AL.

Conclusion: These results suggest that ICG-NIFA might be a valuable tool to reduce the rate of AL in sigmoid and rectal resections in an educational setting.

https://pubmed.ncbi.nlm.nih.gov/35425807/

Radical re-resection has been demonstrated beneficial in incidental gallbladder cancer (iGBC) stages ≥ pT1b. Anatomical resection (AR) of segments IVb-V is recommended, particularly for iGBC and liver-sided tumors. Laparoscopically, this is a challenging procedure, as well as the regional lymphadenectomy, since inflammation from previous surgery can hinder identification of extrahepatic bile ducts. This difficult minimally invasive procedure, facilitated with indocyanine green (ICG) fluorescence enhancement is herein didactically demonstrated.

Methods: A 73 y. o. female patient underwent laparoscopic cholecystectomy for cholelithiasis. An iGBC -pT2b with positive cystic node-was found. Completion radical surgery was decided. Before surgery, 1.5mg of ICG was intravenously administered. A regional lymphadenectomy (stations 5-8-9-12-13) was safely performed: ICG allowed for bile duct visualization despite scarring from previous procedure. AR (IVb-V) was performed based on a glissonian-pedicle approach. After completing the procedure, a new dose of ICG was administered to discard ischemic areas in the remnant.

Results: Total operative time was 359 min. Intermittent Pringle maneuver resulted in <50 ml bleeding. Hospital stay was 3 days. Pathological examination revealed no residual tumor in the liver bed. Ten lymph nodes were resected; 3 of them (2 retroportal and 1 common hepatic artery) showing tumoral invasion. After surgery, 6 cycles of adjuvant chemotherapy (Gemcitabine-Oxaliplatin) was administered.

Conclusions: Laparoscopic radical surgery (AR of segments IVb-V plus regional lymphadenectomy) for iGBC is feasible and safe [4]. ICG fluorescence can be of help to identify hilar structures and rule out areas of ischemia.

https://pubmed.ncbi.nlm.nih.gov/35429730/

In the guidance, the two organizations recommend that elective surgery be delayed for seven weeks after a SARS-CoV-2 infection in unvaccinated patients. There is insufficient evidence to make recommendations for vaccinated patients who become infected with COVID-19, the societies concluded. The guidance, published by the two societies on Feb. 22, is intended to aid hospitals, surgeons, anesthesiologists and proceduralists in evaluating and scheduling surgical patients.

Overall, both societies recommend that elective operations be performed in patients after COVID-19 infection only when anesthesiologists and surgeons agree to jointly proceed with an operation. The decision to operate should be based on a patient’s infectious status and take into account the potential risks of proceeding with surgery versus further delaying an operation, according to the statement. The updated recommendations are based on evidence that emerged over the last year.

https://www.generalsurgerynews.com/In-the-News/Article/04-22/Latest-Guidance-on-Elective-Surgery-in-COVID-19-Patients-Released/66650

Arterialized venous flaps (AVFs) are an innovative option in hand reconstruction. Their exact vascular physiology and survival mechanisms remain unclear. We report on two hand reconstruction cases with AVFs. Indocyanine green laser angiography was used to assess vascular perfusion of the flaps. A notable change in flap perfusion was seen by 48 h post-operatively with normalization of shunting and progression to a diffuse perfusion pattern resembling traditional flaps. Flap survival was attributed to reversed shunting at the microvascular level occurring within the first 48 h post-operatively.

https://pubmed.ncbi.nlm.nih.gov/35368582/

Meta-analyses have demonstrated that indocyanine green (ICG) can effectively prevent anastomotic leakage (AL) after colorectal surgery. This study was conducted to evaluate the value of ICG for the prevention of AL following colorectal surgery.

Results: Twenty studies (5 RCTs and 15 PSM studies) with a total of 5,125 patients were included. ICG did not reduce the reoperation rate (OR, 0.71; 95% CI, 0.38, 1.30), conversion rates (OR, 1.34; 95% CI, 0.65, 2.78), or mortality (OR, 0.50; 95% CI, 0.13, 1.85), but ICG did reduce the incidence of AL (OR, 0.46; 95% CI, 0.36, 0.59) and symptomatic AL (OR, 0.48; 95% CI, 0.33, 0.71), and reduced the length of hospital stay (MD,-1.21; 95% CI,-2.06,-0.35) and intraoperative blood loss (MD,-9.13; 95% CI,-17.52,-0.74). In addition, ICG use did not increase the incidence of total postoperative complications (OR, 0.93; 95% CI, 0.64, 1.35), postoperative ileus (OR, 1.26; 95% CI, 0.53, 2.97), wound infection (OR, 0.76; 95% CI, 0.44, 1.32), urinary tract infection (OR, 0.87; 95% CI, 0.30, 2.59), pulmonary infection (OR, 0.23; 95% CI, 0.04, 1.45), urinary retention (OR, 1.08; 95% CI, 0.23, 5.04), anastomotic bleeding (OR, 1.53; 95% CI, 0.27, 8.60), anastomotic stricture (OR, 0.74; 95% CI, 0.24, 2.29), or operative time (MD,-9.64; 95% CI,-20.28, 1.01).

Conclusions: ICG can effectively reduce the incidence of AL, without prolonging the operation time or increasing postoperative complications in colorectal surgery.

https://pubmed.ncbi.nlm.nih.gov/35372484/

Background: Indocyanine green (ICG) angiography has proven useful in assessing skin flap perfusion in plastic and reconstructive surgeries. This research aimed to explore its role in decision making about skin-sparing in children’s acute trauma.

Methods: A total of 19 patients suffering with acute trauma from January 2019 to September 2021 were retrospectively assessed. Both ICG angiography and clinical judgment were performed to evaluate skin tissue viability. The intraoperative decisions for each case depended on the specific condition of the traumatic wound, including tissue perfusion, skin defect area, and location of the wound. Postoperative vascular imaging software was used to quantify the tissue perfusion, and the duration of postoperative follow-up was from 6 to 18 months.

Results: Among them, 18 (94.7%) patients experienced treatments according to ICG angiography and did not develop postoperative necrosis. One case with right forearm trauma suffered from partial necrosis. Hypertrophic scar and local infection were the independent complications, which were managed by symptomatic treatment.

Conclusion: ICG angiography may reduce the risk of postoperative necrosis and renders a promising adjunctive technique for surgeons to make reasonable decisions in skin sparing in acute pediatric trauma.

https://pubmed.ncbi.nlm.nih.gov/35372153/