Author: fidelmac

Background: The safety and efficiency of minimally invasive approaches for liver resection have been confirmed (Wakabayashi in Ann Surg, 2015). However, laparoscopy suffers from several limitations due to technical difficulties, particularly for difficult hepatectomy with lymphadenectomy, biliary, and vascular reconstruction. Robotic assets could improve accessibility for difficult liver resections. Patients and methods: A 56-year-old woman was treated for a hilar cholangiocarcinoma, Bismuth 3b.

Results: A robotic anatomical left hepatectomy extended to caudate lobe and common biliary duct was decided. A Da Vinci X robot was used. The procedure was performed with a second surgeon positioned between the patient’s legs. Left hepatectomy was extended to common biliary duct and caudate lobe. A four-hands parenchymal dissection (Camerlo in J Robot Surg, 2020) was performed with laparoscopic ultrasonic dissector and robotic irrigated bipolar, guided by indocyanine green. Axis of deep transection line was maintained using the EndoWrist function and exposure with a fourth arm. No pedicle clamping was necessary. Segment 1 was released with a mediocaudal approach. Lateral portal vein resection was performed after parenchymal transection was completed. Hepaticojejunostomy was done separately to the right anterior and posterior biliary duct. Operation time was 420 min, and estimated blood loss was 100 ml. The postoperative course was uneventful. The patient was discharged on postoperative day 8. Pathological findings revealed a 15-mm hilar cholangiocarcinoma with complete resection and eight lymph nodes, all negative.

Conclusions: Robotic approaches could improve accessibility to minimally invasive liver resection of Klatskin tumor.

https://pubmed.ncbi.nlm.nih.gov/34994903/

Background: In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty.

Methods: Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3) kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty.

Results: The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29) cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being “good” or “excellent” and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts.

Conclusion: USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

https://pubmed.ncbi.nlm.nih.gov/34985152/

The aim of this study was to quantify Fluorescence angiography with indocyanine green (ICG) in colorectal cancer anastomosis, determine influential factors in its temporary intensity and pattern, assessing the ability to predict the AL, and setting the cut-off levels to establish high- or low-risk groups. Retrospective analysis of prospectively managed database, including 70 patients who underwent elective surgery for colorectal cancer in which performing a primary anastomosis was in primary plan. In all of them, ICG fluorescence angiography was performed as usual clinical practice with VisionSense™ VS Iridium (Medtronic, Mansfield, MA, USA), in Elevision™ IR Platform (Medtronic, Mansfield, MA, USA). Results: A statistical relationship was found between AL and the lower Fpos and Slope. The decision of changing the subjectively decided point of division did not demonstrate statistical difference on the further development of AL. All parameters were analyzed to detect the cut-off related with AL. Only in case of Fpos lower than 158.3 U and Slope lower than 13.1 U/s p-value were significant. The most valuable diagnostic parameter after risk stratification was the Negative Predictive Value.

Conclusion: Quantitative analysis of ICG fluorescence in colorectal surgery is safe and feasible to stratify risk of AL. Hypertension and location of anastomosis influence the intensity of fluorescence at the point of section. A change of division place should be considered to avoid AL related to vascular reasons when intensities of fluorescence at the point of section is lower than 169 U or slopes lower than 14.4 U/s.

https://pubmed.ncbi.nlm.nih.gov/34988740/

Indocyanine green (ICG) is a fluorescent dye taken up and almost exclusively cleared by the liver. Measurement of its clearance and visualization of its fluorescence make it suitable for a number of potential applications in liver transplantation including assessment of liver function and real-time assessment of arterial, venous, and biliary structures. ICG clearance can be used to assess donor graft quality before procurement and graft metabolic function before transplant using normothermic ex vivo machine perfusion.

ICG clearance in the post-liver transplantation period is able to predict recipient outcomes with correlations to early allograft dysfunction and postoperative complications. After absorbing light in the near-infrared spectrum, ICG also emits fluorescence at 835 nm. This allows the assessment of vascular patency after reconstruction and patterns of liver perfusion in real time. ICG perfusion patterns after revascularization are also associated with posttransplant graft function and survival. ICG fluorescence cholangiography is routine in a number of centers and acts as an aid to identifying the optimal point of bile duct division during living donor liver transplantation to optimize safety for both donor and recipient.

In summary, ICG is a versatile tool and has a number of useful applications in the liver transplantation journey including assessment of liver function, perfusion assessment, and cholangiography.

https://journals.lww.com/transplantjournal/Abstract/9000/Current_and_Potential_Applications_for_Indocyanine.95111.aspx

The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing).

Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions.

Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03).

Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01).

This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy.

https://journals.lww.com/plasreconsurg/Abstract/2021/01000/Hyperbaric_Oxygen_Therapy_in_Management_of.40.aspx

and further commentary on the study

https://journals.lww.com/plasreconsurg/Fulltext/9900/Hyperbaric_Oxygen_Therapy_in_Management_of.586.aspx

Aim: Anastomotic leakage represents the most fearful complication in colorectal surgery. Important risk factors for leakage are low anastomoses and preoperative radiotherapy. Many surgeons often unnecessarily perform a protective ileostomy, increasing costs and necessitating a second operation for recanalization. The aim of this study was to evaluate the role of indocyanine green in assessing bowel perfusion, even in cases of a low anastomosis on tissue treated with radiotherapy.

Patients and methods: Two groups of patients were selected: Group A (risky group) with only low extraperitoneal rectal tumors (<8 cm) previously treated with neoadjuvant chemo-radiotherapy; group B (no risk group) with only intraperitoneal rectal tumors (>8 cm), not previously treated with neoadjuvant therapy. Clinical postoperative outcome, morbidity, mortality and anastomotic leakage were compared between these two groups.

Results: In group A, comprised of 35 patients, the overall complication rate was 8.6%, with two patients developing anastomotic leakage (5.7%). In group B, comprised of 53 patients, the overall complication rate was 17% with four cases with anastomotic leakage (7.5%). No statistical difference was observed for conversion rate, general complications, or anastomotic leakage. No statistical differences were observed in clinical variables except for American Society of Anesthesiologist score (p=0.04). Patients who developed complications during radiotherapy had no significant differences in postoperative outcomes compared with other patients.

Conclusion: Indocyanine green appears to be safe and effective in assessing the perfusion of colorectal anastomoses, even in the highest-risk cases, potentially reducing the rate of ileostomy. The main limitation remains the lack of a universally replicable standard assessment.

https://pubmed.ncbi.nlm.nih.gov/34969727/

To report surgical technique, perioperative, oncological, and mid-term functional outcomes in a single-center purely off-clamp robotic partial nephrectomy series for totally endophytic masses. A retrospective analysis of a prospectively collected, institutional review board-approved renal cancer database was carried out to include patients with a totally endophytic renal tumor treated with off-clamp robotic partial nephrectomy between January 2013 and December 2020 at our center.

Preoperative indocyanine green renal mass marking was performed in 33 patients, in whom the tumor was vascularized by a specific feeding artery.

Surgical steps, perioperative, oncological and functional data were reported. Fifty-six consecutive patients with totally endophytic renal masses were treated. The median tumor diameter was 3 cm, and median PADUA and R.E.N.A.L. scores were both 10. The median operative time was 82 min. Low-grade Clavien complications occurred in two patients (3.6%) and high-grade Clavien complications were observed in four patients (7.1%). Positive surgical margins were detected in one patient; 2-year recurrence-free, cancer-specific, and overall survival rates were 100%, 100%, and 98.2%, respectively. At a median follow-up of 24 months, new onset of chronic kidney disease stage 3b occurred in one patient. At last follow-up, the median estimated glomerular filtration rate was 77 mL/min, with a median estimated glomerular filtration rate percent decrease of 5.5%. Trifecta was achieved in 91% of patients.

Conclusions

Purely off-clamp robotic partial nephrectomy is a feasible and safe surgical approach, even in totally endophytic renal tumors, providing a favorable perioperative complications rate, excellent oncological outcomes, and negligible impact on renal function at mid-term follow-up. Indocyanine green preoperative marking of endophytic renal tumors represents a useful tool for rapid intraoperative identification of the mass, real-time control of resection margins, and a more precise dissection.

https://onlinelibrary.wiley.com/doi/10.1111/iju.14763

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Anastomotic leakage after intestinal resection is one of the most serious complications of surgical intervention for hollow viscus injury. Adequate vascular perfusion of the anastomotic site is essential to prevent anastomotic leakage. Near-infrared imaging using indocyanine green (NIR-ICG) is useful for the objective assessment of vascular perfusion. The aim of this study was to evaluate the association of NIR-ICG with intestinal and mesenteric injuries. This was a retrospective, single-center study of patients undergoing surgery for intestinal and mesenteric injuries. NIR-ICG was used to evaluate vascular perfusion.

Postoperative complications were assessed between NIR-ICG and non-NIR-ICG groups. The use of NIR-ICG was associated with a lower incidence of Clavien-Dindo grade ≥ III complications with a statistical tendency (p = 0.076). When limited to patients that underwent intestinal resection, the use of NIR-ICG was significantly associated with a lower risk of perioperative complications (p = 0.009). The use of NIR-ICG tended to associate with the lower incidence of postoperative complications after intestinal and mesenteric trauma surgery. NIR-ICG was associated with a significantly lower risk of complications in patients undergoing intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful for intestinal and mesenteric trauma.

AL increases mortality, length of hospital stay, 30-day readmission, and postoperative infection. As a result, hospital costs increased by more than $25,000 in the United States and more than €50,000 in Europe when compared to low-cost ICG. Complications, not limited to AL, doubled the length of hospital stay, increased the average total cost by $25,000, and decreases total balance and turns negative, resulting in a large loss.  

The use of NIR-ICG tended to associate with the lower postoperative complications of intestinal and mesenteric trauma. In addition, the use of NIR-ICG was associated with lower complications with statistical significance after intestinal resection. The NIR-ICG procedure is simple and quick and is expected to be useful in intestinal and mesenteric trauma.

https://www.nature.com/articles/s41598-021-03361-1

The superficial temporal artery (STA) frontal branch flap is susceptible to venous congestion because of its unpredictable and variable outflow. The authors applied indocyanine green angiography in identifying the superficial temporal vessels to help surgeons with proper flap designs to avoid severe complications. A retrospective review from 2015 to 2020 was conducted. All the patients who underwent indocyanine green angiography before forehead flap transfer for facial defect reconstruction were reviewed.

The STA and vein were observed using indocyanine green angiography preoperatively. The relationship between the artery and vein was investigated. The venous anatomy was analyzed to guide the pedicle design. The survival of the flap and complications were assessed. A total of 12 patients were identified and included in this study. Indocyanine green angiography allows clear visualization of the detailed anatomy of the STA and vein.

The frontal branch of the vein had great variations and generally diverged from the arterial branch. The tiny venae comitantes provided sufficient drainage for 2 small forehead flaps. The frontal branch of the vein entered the forehead and was used as the outflow channel in 4 patients. The parietal branch of the vein, which consistently gave off secondary tributaries to the superior forehead, was included in the pedicle in 6 patients. All flaps survived without complications. Indocyanine green angiography provided accurate localization of the superficial temporal vessels. This technique may be helpful in the precise planning forehead flap surgeries and in avoiding the risk of venous congestion.

https://journals.lww.com/jcraniofacialsurgery/Abstract/9000/Use_of_Indocyanine_Green_Angiography_to_Identify.91981.aspx